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Principles of Surgery. 




BY 



N. SENN M.D., Ph.D., LL.D., 

Professor of Practice of Surgery and Clinical Surgery in Rush Medical College, Chicago ; Professor of Surgery 

in the Chicago Polyclinic ; Attending Surgeon to the Presbyterian Hospital ; Surgeon-in-Chief to St. Joseph's 

Hospital ; ex-President American Surgical Association, German Congress of Surgeons. Association of 

Military Surgeons of the United States, Chicago Medical Society ; Member of the American 

Surgical Association, American Medical Association, Illinois State Medical Society, 

Chicago Medical Society, Southern Gynaecological and Surgical Society, 

Chicago Gynaecological Society ; Honorary Member of the Academy 

of Medicine of Mexico, Edinburgh Medical Society, Congress 

of Surgeons of Belgium ; Corresponding Member of the 

Harveian Medical Society, London. 



SECOND EDITION. THOROUGHLY REVISED. 



Illustrated oaith 178 Wood~Engravings and 
Colored Plates. 





PHILADELPHIA : 

THE F. A. DAVIS COMPANY, PUBLISHERS. 

LONDON : 

F. J. REBMAN 
1895. 



OCT 19 189 $ 

if I If* 
44 






\ 






COPYRIGHT, 1890, 

BY 

F. A. DAVIS. 



COPYRIGHT, 1895, 

BY 

THE F. A. DAVIS COMPANY. 



[Registered at Stationers' Hall, London, Eng.] 



Philadelphia, Pa., U. S. A. 

The Medical Bulletin Printing-IIouse, 

1916 Cherry Street. 



PREFACE TO FIRST EDITION. 



A modern work on the principles of surgery in the 
English language has become a generally and well-recognized 
necessity. The recent great discoveries relating to the etiology 
and pathology of surgical diseases have made the text-books of 
only a few years ago old and almost worthless. The many 
treatises on surgery, by American and English authors, which 
have made their appearance in rapid succession during the last 
ten years or more, are replete with valuable practical information, 
but most of them are defective in those parts relating to the 
matter treating of the fundamental principles of the art and 
science of surgery. 

It has been my aim to write a book for the student and 
general practitioner which should, at least in part, fill this gap 
in surgical literature, and which should serve the purpose of a 
systematic treatise on the causation, pathology, diagnosis, prog- 
nosis, and treatment of the injuries and affections which the 
surgeon is most frequently called upon to treat. The successful 
study and practice of any branch of the healing art require a 
thorough knowledge of the principles upon which it is based. 
The student who has mastered the principles of surgery will 
have no difficulty in applying his knowledge in practice, while 
the one who has burdened his memory with numerous details 
to meet special indications is always at a loss in making prompt 
and judicious use of his therapeutic resources when confronted 
by rare lesions or unexpected emergencies. 

(m) 



IV PREFACE. 

In writing this book it has been my intention to keep in 
constant view the difference between the cellular processes, as 
we observe them in regeneration and inflammation, and to 
connect the modern science of bacteriology more intimately with 
the etiology and pathology of surgical affections than has here- 
tofore been done by most authors who have written on the 
same subjects. In showing the direct etiological relationship 
which exists between certain pathogenic micro-organisms and 
definite pathological processes, I have frequently made liberal 
use of the experimental and clinical material contained in my 
work on " Surgical Bacteriology." When the subject of 
tumors was reached it was found that the manuscript had 
become so voluminous that it was deemed advisable to publish 
the volume without this part of the intended scope of the 
work, — an arrangement to which the publisher kindly gave his 
consent. It is the author's intention to make good this defect 
by the preparation, in the near future, of a special work on 
" The Pathology and Surgical Treatment of Tumors." 

With few exceptions the sources from which my informa- 
tion was taken are not given, as a copious bibliography would 
have required considerable valuable space. At the same time 
the author hopes that he has presented the views and opinions 
of the authorities quoted with sufficient clearness and thorough- 
ness to render a resort to the original articles, in most instances, 
unnecessary. Among the text-books which I have consulted I 
desire to mention the following : Histology : Klein, Schafer, 
Heitzmann, and Satterthwaite. Pathology : Klebs, Hamilton, 
Birch-Hirschfeld, Paget, Virchow, Coates, Lebert, Rindfleisch, 
Delafield, and Prudden. The Principles of Surgery: Konig, 
Hueter-Lossen, Landerer, Billroth- Winiwarter, and Van Buren. 
Bacteriology : Fluegge, Baumgarten,* and Cruikshank. The 



PREFACE. V 

illustrations were selected from modern text-books not readily 
accessible to the average student. 

A prolonged absence from home made it impossible for the 
author to attend to the proof-reading, and he asks the indulg- 
ence of the reader for any imperfections which may appear in 
the book from any sources for which he cannot be held person- 
ally responsible. 

Should this volume become the means of lightening and 
facilitating the student's work in acquiring a thorough knowl- 
edge of the fundamental principles of surgery, and of serving as 
a useful source of information for the busy general practitioner, 
the author will feel abundantly rewarded for the many sleepless 
nights which were required in its preparation. 

N. Senn. 

Milwaukee, October, 1890. 



PREFACE TO. SECOND EDITION. 



Five years have elapsed since the first edition made its 
appearance. Since that time many notable advances in pathol- 
ogy have been made, and the art and science of surgery have 
been enriched by many valuable additions. The favorable 
reception accorded the first edition by the profession and the 
desire of the publishers to keep the work abreast with the 
times have induced the author to undertake a thorough re- 
vision. In performing this task it has been found necessary to 
add much new material, thus enlarging considerably the size 
and scope of the work. A number of new subjects which 
should be included in a treatise on the " Principles of Surgery " 
have been inserted, and many of the chapters have been 
elaborated by insertion in appropriate places of facts elucidated 
by the most recent investigations. More than fifty new illus- 
trations, many of which are original, have been added. The 
technique of a number of operations is described and illustrated 
for the special purpose of demonstrating, from a practical stand- 
point, the value of a thorough knowledge of the complicated 
reparative processes in the treatment of injuries and disease by 
surgical intervention. The author has kept his promise made 
in the preface to the first edition, as a work on " The Pathology 
and Surgical Treatment of Tumors " leaves the press almost 
simultaneously with the present edition. Dr. H. B. Stehman 
has placed the author under many obligations in relieving him 
of the difficult and monotonous task of proof-reading. 

N. Senn. 

Chicago, August, 1895. 

(vii) 



TABLE OF CONTENTS. 



PAGE 

Preface, iii 

Table of Contents, ix 

List of Illustrations, xiii 

CHAPTER I. 
Regeneration, 1 

CHAPTER II. 
Regeneration of Different Tissues, 30 

CHAPTER III. 
Inflammation, 79 

CHAPTER IV. 
Inflammation (continued), 105 

CHAPTER V. 
Pathogenic Bacteria, 142 

CHAPTER VI. 
Necrosis, 171 

CHAPTER VII. 

Necrosis (continued), 189 

(ix) 



X TABLE OF CONTENTS. 

CHAPTER VIII. page 

Suppuration, 204 

CHAPTER IX. 
Suppuration (continued), . 226 

CHAPTER X. 
Ulceration and Fistula, 250 

CHAPTER XI. 
Suppurative Osteomyelitis, 255 

CHAPTER XII. 

Suppuration in Large Cavities ; Abscess of Internal Organs, 288 

CHAPTER XIII. 
Septicemia, 332 

CHAPTER XIV. 
Pyemia, 362 

CHAPTER XV. 
Erysipelas, 389 

CHAPTER XVI. 
Tetanus, 414 

CHAPTER XVII. 
Hydrophobia, 436 

CHAPTER XVIII. 
Surgical Tuberculosis, 452 



TABLE OF CONTENTS. XI 

CHAPTER XIX. PAGE 

Clinical Forms of Surgical Tuberculosis, 481 

CHAPTER XX. 

Tuberculosis of Lymphatic Glands and Peritoneum, . . . 505 

CHAPTER XXI. 
Tuberculosis of Bones and Joints, 524 

CHAPTER XXII. 

Tuberculosis of Tendon-Sheaths, etc., 565 

CHAPTER XXIII. 
Actinomycosis Hominis, 591 

CHAPTER XXIY. 
Anthrax, 613 

CHAPTER XXV. 
Glanders, , 632 

Index, 647 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. A wound twenty-six h6urs old (Thiersch), 4 

2 " " " " 5 

3. Quiescent nucleus (Flemming), 8 

4. Living cell of salamander (Flemming), 8 

5. Endothelial cells (Flemming), 9 

6. Epithelial cell of salamander (Flemming), 10 

7. " " " 10 

8. " " " 11 

9. Cell division (McKendrick), 13 

10. Granulating wound (Billroth- Winiwarter), 14 

11. Granulation tissue from wound (Hamilton), 15 

12. Superficial capillaries of a wound beginning to granulate (Hamilton), . . .17 

13. Formation of new blood-vessels by budding (Arnold), 18 

14. Development of blood-corpuscles in connective-tissue cells, and transformation of 

the latter into capillary blood-vessels (Fluegge), 19 

15. Granulating wound undergoing cicatrization (Landerer), 20 

16. Embryonal connective-tissue cell undergoing transformation into mature state 

(Ziegler), 21 

17. Wandering epithelial cells from frog (Klebs), 22 

18. Corneal corpuscles in a state of proliferation (Senftleben), 32 

19. Wound of cornea (von Wyss), 33 

20. Rhinoplasty and transplantation of large skin grafts (Thiersch), . . . .39 

21. Microscopical appearances of the interior of artery of dog, . . . ... 42 

22. Mici'oscopical appearances of the interior of vein of dog, 43 

23. Femoral artery of dog fifty days after double ligation with silk (Natural size), . 45 

24. Collateral circulation eight months after ligation of the aorta in a dog (Luigi 

Porta), 46 

25. Muscular fibres near a wound in a state of proliferation (O. Weber), . . .48 

26. Muscle suture, 49 

27. Tenorrhaphy (Esmarch), 50 

28. Tendoplasty (Esmarch), - 50 

29. Secondary suturing of extensor tendons of fingers by the suture d, distance, . . 51 

30. Tendon elongations, 52 

31. Section through callus (Bajardi), 54 

32. Transverse section through callus, 55 

33. Old method of bone suture, 60 

34. Improved bone suture, 60 

35. Wire drawn through the perforation, 60 

36. Wire cut in the centre and each half twisted separately, 60 

37. Senn's hollow intra-osseous splint, 61 

38. Circular bone ferrule for humerus or femur made of an ox femur, . . . .61 

39. Triangular bone ferrule for tibia made of an ox tibia, 61 

40. Wide perforated bone ferrule, 61 

41. Oblique fracture of femur united by bone ferrule, . . . . . .62 

42. Transverse fracture of humerus immobilized by a wide perforated bone ferrule, . 62 

43. Senn's splint apparatus for treating fracture of the neck of femur, . . .63 

(xiii) 



XIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

44. Sena's splint apparatus applied, 63 

45. Wound of kidney (Tillmanns), 65 

46. Healing of wound of liver (Tillmanns), 65 

47. Tubular suture of Van Lair with decalcified bone-tube, 69 

48. Nerve-fibre in a state of regeneration (Gluck), 70 

49. Longitudinal section through nerve (Gluck), 71 

50. Nerve suture, showing application of direct and paraneural sutures, . . .73 

51. Neuroplasty (Letievant), 76 

52. Cross sutures (Tillmanns), 76 

53. Capillary vessels of the frog's mesentery (Klein), 81 

54. Leucocyte, showing reticulum of protoplasmic strings (Klein), . . . .82 

55. Change of forms of a moving leucocyte by amoeboid movements (Klein), . . 83 

56. Amoeboid movements of red blood-corpuscles (Leonard), 84 

57. Third corpuscle (Eberth and Schimmelbusch), 85 

58. Normal circulation in frog's web (Landerer), 91 

59. Capillaries of frog's web in a state of hyperseinia soon after application of irritant 

(Landerer), 92 

60. Leucocyte passing through capillary wall (Landerer) , 99 

61. Inflammation of frog's web at stage where capillary stream is imbedded by com- 

mencing emigration (Landerer), 101 

62. Germinating endothelium (Hamilton), 109 

63. Omentum of young dog, experimentally inflamed (Hamilton), .... 110 

64. Acute pleurisy (Hamilton), Ill 

65. Artificial keratitis (Hamilton), 118 

66. Phagocytosis. Struggle between anthrax bacillus and leucocyte, .... 125 

67. Hueter's infuser, 132 

68. Cold coil (Esmarch), 136 

69. Cold coil for the head (Leiter), 137 

70. Different forms of bacteria (Baumgarten), 143 

71. Zoogloea, .144 

72. Endogenous spore production in bacillus anthracis cultivated upon meat-infusion 

peptone-gelatin (Baumgarten), 145 

73. Spore of bacillus of anthrax (De Bary), 146 

74. Gelatin cultures following surface inoculation (Fluegge), 148 

75. Cultures in gelatin growing in the track made by the needle (Fluegge), . . 149 

76. Experimentally-produced growth of streptococci in centre of cornea of rabbit 

(Baumgarten), 175 

77. Vertical section through a subcutaneous abscess (Baumgarten. Colored), . . 209 

78. Microscopic pictures of staphylococcus (Rosenbach), 215 

79. Micrococcus pyogenes tenuis (Rosenbach), 217 

80. Microscopic picture of streptococcus pyogenes (Rosenbach), 217 

81. Bacillus pyogenes foetidus (Fluegge), 218 

82. Bacillus pyocyaneus (Fluegge), 218 

83. Bacillus pyocyaneus, 219 

84. Gonococcus (Bumm), 220 

85. Gonorrhoeal pus, 220 

86. Gonorrhoeal conjunctivitis (Bumm. Colored), 221 

87. Bacillus coli communis, 221 

88. White corpuscles and pus-corpuscles (Koch), 222 

89. Fragmentation of nucleus in leucocytes undergoing transformation into pus-cor- 

puscles (Landerer), 224 

90. Pus with staphylococcus (Fluegge), 225 



LIST OF ILLUSTRATIONS. XV 

FIG. PAGE 

91. Pus with streptococcus (Fluegge), 225 

92. Pus-corpuscles (Billroth- Winiwarter), 225 

93. Infiltration of connective tissue of cutis, with beginning suppuration in the 

centre (Billroth- Winiwarter), 230 

94. Vessels (artificially injected) from walls of an abscess artificially produced in the 

tongue of a dog (Billroth- Winiwarter), 232 

95. Irrigating apparatus, 240 

96. Osteomyelitis of the tibia, 263 

97. " " " 265 

98. Hollow, padded, posterior splint (Esmarch), 270 

99. Board splint for upper extremity (Esmarch), 271 

100. Wire splint (Esmarch), 271 

101. Plaster of-Paris splint, 272 

102. Incision for neurotomy of the tibia, 280 

103. Bone-cavity after removal of sequestrum and granulations in necrosis of the 

tibia (Esmarch), 281 

104. Inversion of soft tissues on each side into the bone-cavity (Ncuber), . . . 282 

105. Healing of bone-cavity (Neuber), 282 

106. Osteoplastic necrotomy (Bier), 284 

107. Gonococcus (Bumm), 289 

108. Motor areas, 303 

109. Wilson's cyrtometer, 305 

110. Wilson's cyrtometer applied, 305 

111. Head, skull, and cerebral fissures (adapted from Marshall), 306 

112. Vein of the diaphragm of a septicemic mouse (Koch), 334 

113. Bacillus of mouse-septicaemia (Fluegge), . . . 335 

114. Glomerulus of a septicemic rabbit (Koch), 336 

115. Capillary vessels surrounding the intestinal glands of a septicemic rabbit 

CKoch), .337 

116. Bacillus of malignant oedema (Koch), 338 

117. Spore formation in bacillus of malignant oedema (Fluegge), .... 338 

118. Cultures of bacillus of malignant oedema in gelatin (Fluegge), .... 339 

119. Bacillus saprogenes 1 (Rosenbach), 344 

120. Bacillus saprogenes 2 (Rosenbach), 344 

121. Bacillus saprogenes 3 (Rosenbach), 341 

122. Proteus vulgaris (Hauser), 345 

123. Proteus mirabilis (Hauser), 346 

124. Involution forms of proteus mirabilis (Hauser), 347 

125. Vessel from the cortex of the kidney of a pyemic rabbit (Koch), . . . 365 

126. Suppurating thrombus in vein (Tillmanns), . 367 

127. White thrombus (Landerer), 370 

128. Red thrombus (Landerer), 371 

129. Laminated thrombus in a vein (Birch-Hirschfeld), 372 

130. Thrombo-phlebitis (Billroth), 3*73 

131. Embolus of branch of pulmonary artery (Birch-Hirschfeld), .... 375 

132. Pyemic abscess of lung (Hamilton), 376 

133. Coagulation necrosis from a kidney infarct (Birch-Hirschfeld), .... 377 

134. Pyemic pus (Landerer), 381 

135. Section of ear of rabbit parallel to surface of cartilage. The morbid process 

resembled erysipelas (Koch), 390 

136. Streptococcus erysipelatosis (Baumgarten), 391 

137. Stale culture of streptococcus of erysipelas in gelatin (Baumgarten), . . . 392 



XVI LIST OF ILLUSTRATIONS. 

FIG. PAGE 

138. Section through skin near the margin of the erysipelatous zone (Koch), . . 396 

139. Section of skin in erysipelas (Cornil and Babes), 396 

140. Tetanus bacilli (Frankel-Pfeiffer), 415 

141. Culture of bacillus tetani in nutrient gelatin (Kitasato), 416 

142. A blood-vessel from medulla oblongata in a case of hydrophobia (Coates), . . 445 

143. From the salivary gland in a case of hydi'ophobia (Coates), ..'... 446 
Plate I. Fig. 1, tubercle bacilli containing spores (R. Koch. Colored). Fig. 2, 

tubercle bacilli from a tubercular cavity. (Colored), 456 

144. Giant cell with one tubercle bacillus (Fluegge), 457 

145. Giant cell. Miliary tuberculosis (Fluegge), . . . . . . . 457 

Plate II. Fig. 1, glass-slide preparation from the tissue-juice of a fresh inocu- 
lation tubercle (Baumgarten. Colored). Fig. 2, from encysted bronchial 

glands in miliary tuberculosis (Koch. Colored), 458 

Plate III. Tubercle bacilli (Frankel and Pfeiffer. Colored), . . .458 

146. Vegetations of tubercle bacilli upon sterilized blood-serum (Baumgarten. 

Colored), 459 

147. Tubercle nodule in lymphatic gland, 471 

148. Giant cell from centre of tubercle of lung (Hamilton), ..... 472 

149. Tuberculosis of trochanteric bursa, 473 

150. Section from mucous membrane of pharynx, showing epithelioid cells with a few 

small giant cells (Birch-Hirschfeld) , 474 

151. Fully-developed reticular tubercle of lung (Hamilton), 475 

152. Tuberculosis of trochanteric bursa, 479 

153. Membrane lining tubercular abscess (Landerer), 487 

154. Senn's injection syringe, 491 

155. S-shaped incision in the operation for removal of tubercular glands of the neck, 515 

156. Tubercular focus near the epiphyseal line of the lower end of the femur, . . 529 

157. Tubercular cavity in the internal condyle of the femur (Landerer), . . . 530 

158. Tuberculosis of astragalus (Tillmanns), 531 

159. Tubercular sequestra (Landerer), 532 

160. Tubercular infarct in the head of the femur (Volkmann), 532 

161. Central tuberculosis of the neck of the femur (Volkmann), 542 

162. Tuberculosis of lower epiphysis of femur (Weber), 546 

163. Knee-joint (Albert), 550 

164. Halm's incision for arthrectomy or resection of knee-joint, 557 

165. Interrupted plaster-of-Paris splint for resection of knee-joint, .... 559 

166. Tubercle bacilli in urine (Cornil and Babes), 587 

167. Ray-fungus (Ponfick), 592 

Plate IV. Actinomyces from a section of a maxillary tumor of a cow (Crook- 
shank. Colored), 593 

168. Actinomyces. Section from actinomycotic swelling (Fluegge), .... 597 

169. Actinomyces from lung of cow (Marchand), 606 

170. Anthrax bacilli. Spore formation and spore germination (Koch), . . . 614 

171. Stab-culture of anthrax bacilli in gelatin (Baumgarten), 615 

172. Anthrax colony upon gelatin (Fluegge), 616 

173. Intestinal villus of anthracic rabbit (Koch), 617 

Plate V. Bacillus anthracis (Crookshank. Colored), 618 

174. Anthrax. Section from liver (Fluegge), 625 

175. Bacilli of glanders from a young potato culture (Baumgarten), .... 633 

176. Glanderous nodule from the liver of a field-mouse (Baumgarten), . . . 635 

177. Acute glanders (Birch-Hirschfeld), 641 

178. Section of a glanders nodule (Fluegge. Colored), 643 



PRINCIPLES OF SURGERY. 



CHAPTER I. 

Regeneration. 

The student should first familiarize himself with the histological 
processes as observed during the growth, development, and repair of 
tissues preparatory to a study of inflammation and the various destruct- 
ive processes attending and following it, as in the complicated process 
called inflammation attempts at repair are always manifested, and after 
its subsidence destruction alwa}'S gives way to regeneration. 

Regeneration includes a multitude of processes which are intended 
to repair the normal physiological waste of the tissues in the living body 
or to restore tissues lost by injury or disease. In the human body 
normal regeneration or repair of tissues is a physiological process, which 
is essential for the maintenance of the anatomical perfection and func- 
tional activity of the different tissues and organs. In a condition of 
perfect health, in the full-grown body, the normal waste incident to the 
increasing activity of the tissues is balanced by this reparative process, 
while during the development of the body an excess of material is added 
upon which depends the increase of tissue which constitutes growth. 
If cell-destruction is in excess of cell-reproduction atrophy is the inevi- 
table result, and if the function of regeneration is completely suspended 
death must necessarily ensue, the blood being the first tissue the seat of 
extreme atrophic changes, soon to be followed by similar changes in all 
the tissues, resulting in diminution of function proportionate to the de- 
gree of atrophy, and, finally, death from marasmus. 

Studied from a surgical aspect, regeneration includes the process 
observed in the healing of wounds produced by a trauma and the com- 
plete or partial restoration of parts damaged or destroyed by the action 
of chemical substances, extremes of cold or heat, and the various de- 
structive inflammatory processes caused by the presence of specific 
pathogenic microorganisms. Regeneration and inflammation are dis- 
tinct conditions, which should no longer be confounded or considered 
from the same etiological and pathological stand-point. An ideal regen- 
eration takes place without inflammation provided the seat of injury or 
tissue-destruction remains aseptic ; that is, free from pathogenic microbes. 
On the other hand, a regenerative process within or around an inflamma- 
tory focus can only be established in tissues in which the cause which 
has produced the inflammation has not been sufficiently intense to destroy 
the protoplasm of the cells. Under these circumstances the reparative 
process is initiated at a time when the cause which has given rise to the 

(i) 



A PRINCIPLES OF SURGERY. 

inflammation has ceased to be active, or in tissues not deprived of their 
vegetative power by its action. In a circumscribed suppurative inflam- 
mation the cells exposed to the direct action of the pus-microbes and 
their ptomaines are destroyed, and the process of repair starts from the 
abscess-walls and their immediate vicinity, from tissues which have re- 
tained their power of cell-proliferation. Any organ the seat of a tuber- 
cular infection, in w T hich the parasitic cause is not sufficiently intense to 
destroy the vitality of the cells, retains its normal structure and function 
by virtue of this intrinsic power of regeneration of its cells. All repara- 
tive processes consist of homologous cell-development, and the new 
tissue resembles, anatomically and physiologically, the fixed cells from 
which it is produced. The legitimate succession of cells is now a well- 
established law in pathology as well as embryology, and, according to 
this tissue, is never produced by substitution of function. According 
to this histogenetic law, each cell-element possesses an intrinsic vegeta- 
tive power from the earliest embryonal development throughout life, 
which, in case of loss of tissue b}^ injury or disease, enables it to produce 
its own kind and never any other materially different histological struc- 
ture. In conformity with this general law of tissue-production, an injury 
or defect of a nerve-fibre is repaired by proliferation from pre-existing 
cells which compose this structure, epithelial cells are produced only by 
epithelial cells, new vessels are formed from cells which exist in a normal 
vessel-wall, etc. From this stand-point will be considered — 

I. HEALING OF WOUNDS. 

A wound may be defined as a sudden solution of continuit} 7 of any 
of the tissues of the body caused by the application of mechanical force. 
A wound is open or subcutaneous according as the surface covering the 
skin or mucous membrane has been cut or torn or has remained intact. 
Since the introduction of the antiseptic treatment of wounds, the classi- 
fication into open and subcutaneous wounds is no longer of the same 
practical importance, as an open wound, under careful antiseptic treat- 
ment, is at once placed under the same favorable conditions for a satis- 
factory and rapid healing as a subcutaneous wound. All wounds, irre- 
spective of the anatomical structure of the tissues involved, heal by the 
production of new materialfrom pre-existing fixed tissue-cells. The fixed 
tissue-cells at the site of injury being endowed from earliest embiyonal 
life with a peculiar power of adaptation to existing conditions surround- 
ing them, assume active tissue proliferation, and the embiyonal cells thus 
produced constitute the granulation-tissue, which, toward the completion 
of the healing process, is transformed into mature cells, representing the 
tissue or tissues which have undergone the reparative process. 



IMMEDIATE OR DIRECT UNION. 3 

IMMEDIATE OR DIRECT UNION. 

Since the time of John Hunter a great deal has been said and 
written on immediate or direct union of wounds. Hunter believed that 
this method of healing would be accomplished within a few hours, and 
without the interposition of new material between the accurately coapted 
surfaces. Macartney was a supporter of this view, as will be seen from 
the following : " The circumstances under which immediate union is 
effected are the cases of incised wounds that admit of being, with safet} 7 
and propriety, closely and immediately bound up. The blood, if any be 
shed on the surface of the wound, is thus pressed out, and the divided 
blood-vessels and nerves are brought into perfect contact, and union may 
take place in a few hours ; and, as no intermediate substance exists in a 
wound so healed, no mark or cicatrix is left behind." Paget applies this 
method of healing to large wounds where rapid union is accomplished, 
and where, on examination, no interposed tissue is found between their 
edges. Such a case came under his own observation. A patient on 
whom he had performed an operation for the removal of a carcinomatous 
breast died from an attack of erysipelas a few days later. Examination 
showed that firm union had taken place apparently without any inter- 
mediate material. He also made three experiments on rabbits for the 
purpose of studying this rapid method of repair. The hair was removed, 
the skin incised, and the wound accurately sutured. Three days later he 
examined the parts, and found the wound quite firmly united, without 
any macroscopical evidences of inflammation. On microscopical examina- 
tion, he found some exudation material in the immediate vicinity of the 
wound. 

Among the more modern investigators, we find Thiersch still up- 
holding the possibility of immediate union by direct cohesion of similar 
parts. He studied the repair of wounds in the tongue of guinea-pigs. 
The tongue was incised in a longitudinal direction, and the parts were 
examined a few hours to several daj^s after the injury had been in- 
flicted. Before sections were made for microscopical examination the 
lingual vessels were injected with liquid glue stained with carmine. In 
specimens where the wound was only a few hours old lie found, at least, 
parts of the wound firmly adherent, and on microscopical examination 
he satisfied himself that the connective tissue, saturated with blood and 
plasma, had formed an immediate and permanent union. He described 
also a plasmatic circulation in the wound which he considered of great 
importance for the nutrition of the tissues. He believed that these new 
channels, by becoming paved with the adjacent connective cells, could be 
transformed into permanent blood-vessels. 

The same section examined under a higher power furnishes a good 



4 PRINCIPLES OF SURGERY. 

illustration of the part taken by the fixed tissue-cell in the repair of the 

wound. 

Some surgeons still believe in immediate union in the repair of 

wounds of nerves, as many cases have 
been reported where complete restora- 
tion of function was claimed to have 
been established within a few hours 
after nerve suture. Such observations 
are not free from criticism, because 
functional results after nerve suture 
may lead to wrong conclusions, as 
restoration of function in distal parts 
may be owing to the presence of other 
nerves which reach such parts, and 
partly it may be due to physical con- 
F duction of irritation. The occurrence 





Fig. 1.— A Wound Twenty-six Hours Old. {Thiersch.) 

A. Coaptated parts apparently united. Tissues only slightly stained with coloring material of blood ; 
few leucocytes. B, B. Spaces between wound-surfaces filled with red and white blood-corpuscles, some 
of the former well preserved, others showing various degrees of disintegration ; between them, edema- 
tous connective-tissue fibres. C, C show that these fibres are continuous with the connective tissue of 
tbe wound-surfaces. Surface of wound coaptation imperfect ; the epithelial cells dip down into the 
wound. D. A separated cone of new tissue. B. Infiltration of fatty tissue with blood and leucocytes. 
G. Divided muscular fibres, with escaped pieces which have partly undergone colloid degeneration. 
(Hartnack, Obj. 4, Oc. 2.) 



of immediate union was doubted by O'Halleran, a distinguished contem- 
porary of Bell, as may be learned from the following quotation: 
" I would ask the most ignorant tyro in our profession whether he ever 
saw, or heard even, of a wound, though no more than one inch long, 



IMMEDIATE OR DIRECT UNION. 5 

united in so short a time," adding, " These tales are told with more 
confidence than veracity ; healing by inosculation, by the first intention, 
by immediate coalescence without suppuration is merely chimerical and 
opposite to the rules of nature." 

Griissenbauer repeated the experiments of Thiersch and Wywodzoff 
on the healiug of wounds in the tongue of guinea-pigs, and came to 
entirely different conclusions. In wounds eight to twelve hours old he 
found that the margins formed an elliptical space, the separation being 
widest in the middle. The divided muscular fibres had retracted. 




Fig. 2. (Thiersch.) 

A, embryonal cells showing karyokinetie figures; B, lymph-spaces; C, striped masses infiltrated 
with red blood-corpuscles in various stages of disintegration ; D, blood-vessel ; F, fat-tissue. (Hartnack, 
Obj. 8, Oc. 4.) 

imparting to the wound an uneven surface, which was covered with a 
layer of reddish, gelatinous material. In recent wounds the space is 
filled with blood-corpuscles which are often much changed in color, size, 
and shape. In wounds twenty-four to forty-eight hours old the material 
between the surfaces of the wound presented a reticulated appearance, each 
one of the spaces corresponding to a blood-vessel. Contrary to Thiersch, 
he asserts that in this substance no connective tissue can be found ; the 
reticulated structure he attributed to the presence of fibrin, the coagulum 
infiltrating at the same time the adjacent tissues. He believes that the 



b PRINCIPLES OF SURGERY. 

parenchyma fluid takes part in the formation of the coagulum. He 
was unable to verify, by his own observations, the existence of the 
plasma channels described by Thiersch. When the wound-surfaces were 
kept accurately approximated he found few blood-corpuscles, but the 
net-work of fibrin was never absent. In hare-lip operations, and incised 
wounds of the face and scalp, if uninterrupted apposition is maintained 
for a day or two, the parts are found so firmly glued together that the 
belief that immediate union had taken place might still be maintained 
from a superficial examination, but a microscopical examination will 
always reveal the conditions described by Gussenbauer, and the union is 
therefore only apparent, and not real. The surfaces of the wound have 
become adherent by the interposition of an adhesive material. A certain 
amount of coagulation necrosis takes place in every wound, and the 
material thus formed serves as a cement-substance which temporarily 
glues the parts together. This mechanical union, the result of destruc- 
tive chemical changes in the extravasated blood, is the form of union 
which has been wrongly interpreted and described as immediate union. 
This primar}^ adhesion occurs most readily in wounds of dense vascular 
tissue and where approximation and fixation of the edges of the wound 
are most thoroughly secured, — conditions which favor the subsequent 
definitive healing of the wound by the interposition of new tissue. 

UNION BY PRIMARY INTENTION. 

Organic union, the union aimed at in the treatment of all wounds, 
is only obtained by tissue-proliferation from the fixed cells of the injured 
parts, and is completed only after restoration of the continuity of the 
divided structures, and the return, partial or complete, of the functions 
suspended by the injury or disease. Return of structure and function 
to an at least approximately normal standard implies a return of the 
interrupted circulation by the formation of new blood-vessels ; in other 
words, organic union cannot be said to have taken place without an 
adequate supply of new blood-vessels in the new tissue which form a 
capillary collateral net-work between the divided blood-vessels. Such a 
union, even under the most favorable circumstances, cannot be established 
in less than six to eight days, and its attainment may require weeks and 
months. The next method of repair described by John Hunter was 
union by adhesive inflammation. Absence of suppuration and rapid 
union have always been considered as essential features of this mode of 
healing, and corresponds to the healing of wounds per primam inten- 
tionem, — an expression which, for obvious reasons, has been retained 
in modern literature to distinguish it from the method of healing per 
secundem intentionem, where the reparative process is often indefinite!} 7 



UNION BY PRIMARY INTENTION. 7 

delaj^ed by suppuration. All wounds which heal without suppuration 
heal by primary union, either without or with visible granulation tissue. 
An ideal result is obtained if the separated surfaces unite throughout and 
the repair in the depth of the wound is accomplished during the same 
time underneath the united skin or mucous membrane. If there has 
been a considerable loss of surface tissue and the superficial portion of 
the wound cannot be approximated, or, if rapid healing at the surface of 
the wound fails to take place, the wound heals slowly by the formation 
of a larger amount of granulation tissue, and yet, if suppuration does 
not complicate the process it must be said that the wound has healed by 
primary union. This method of healing was exceedingly rare before 
antiseptic surgery was practiced, but since that time it is of frequent 
occurrence. All wounds which heal without suppuration heal without 
inflammation. All inflamed wounds suppurate ; the reparative process 
is delayed until the inflammation has subsided. The proper modern 
classification of wounds in reference to the method of repair consists in 
a distinction between (1) aseptic wounds and (2) infected wounds. 
Aseptic wounds — that is, wounds not contaminated with pathogenic micro- 
organisms — heal without inflammation. An aseptic wound, as a rule, is 
painless, and does not present any of the other witnesses of inflammation. 
The slight swelling and, perhaps, redness are the result of mechanical 
disturbances of the circulation, and subside with the formation of an 
adequate collateral circulation ; hence, from an etiological and pathological 
point of view, we have no legitimate right to apply the term inflammation 
to such a method of repair. Koenig makes the statement that the 
product of tissue-proliferation in the healing of an aseptic wound is not 
in excess of the local demand ; hence, the process is purely one of regen- 
eration, and not inflammation. Hueter was one of the first who insisted 
on limiting the meaning of the term inflammation, which he wished to 
have applied only to destructive processes caused by the action of 
specific microbes. In an aseptic wound the fixed tissue-cells assume 
tissue-proliferation, by virtue of their intrinsic vegetative power, within 
a few hours after the injury has been inflicted, and all the permanent 
material utilized in the process of repair is derived from this source. 
The leucocytes serve a useful purpose in the temporary closure of 
divided capillary vessels and in the formation of the temporary cement- 
substance by which the surfaces of the wound are mechanically glued 
together, and, lastly, as food for the embryonal cells, but they take no 
active part in the production of new tissue. 

In studying the process of healing in wounds as well as in the con- 
sideration of regeneration in general, it is of the greatest importance to 
become familiar with the histological changes which precede and attend 



8 



PRINCIPLES OF SURGERY. 



the formation of new tissue; hence, in this connection should be given a 
description of 

KARYOKLNESIS. 

Karyokinesis, or karyomitosis, as described by Flemming, is the in- 
direct reproduction of cells as compared with direct cell-division by 
segmentation. It is a process by which the net-work of chromatin 
threads within the nucleus undergoes great development, and is subject 
to certain transformations of form, which are instrumental in effecting 
division of nucleus and cell. The term karyokinesis was first used by 
Schleicher, and the first accurate description of the process, as seen in 
the cells of a number of animals, simple in form and structure, was given 
by Butschli in 1876. The modern definition of a cell is much more com- 
plicated than that given by Schleiden and Schwann, as recent researches 
have shown that it is not such a simple structure as it was formerly 





Fig. 3.— Quiescent Nucleus. Epithelial, 
Cell of Salamander Entering upon 
the "Glomerular" Phase. {Flem- 
ming.) 



Fig. 4.— Living Cell of Salamander. 

(Flemming.) 

A, granules aggregated round a pole of the cell ; B, 

coils of " glomerular " net-work ; C, cell-body. 



believed to be. When we speak of a cell now we mean a mass of cir- 
cumscribed living substance, with or without an envelope, which con- 
tains as an essential element in its interior a nucleus, with the property 
of forming new compounds out of substances taken into it, and is capable 
of reproduction by division. Both the nucleus and cell are composed of 
threads and intermediate substance. The cell-body consists of threads 
somewhat irregularly distributed, seldom forming a net-work, embedded 
in a homogeneous substance. The nuclear threads stain with hsema- 
toxylin and safranin, and hence are called chromatin threads, which are 
arranged in a net-like figure, the meshes of which are filled with a sub- 
stance which cannot be stained, and hence is named by Flennning 
achromatin. The nucleus is surrounded by a membrane composed of 
two layers ; the inner can be stained, but not the outer. The nucleoli, 
usually multiple, are made up of a substance more refractile than the 
structures described in the nucleus. They are round and smooth, and 



KARYOKINESIS. 



9 



either suspended in the net-work or between the threads. The nucleus 
in a cell that is not in a condition of functional activity is said to be in 
a quiescent or resting state. 

At this time the chromatin threads become transformed into a sort 
of skein, formed apparent!} 7 of one long, convoluted thread ; the inner 
layer of the nuclear membrane and nucleoli disappear, or are incorporated 
into the achromatin substance of the nucleus. The development of the 
net-work of the chromatin substance in the nucleus undergoes five phases 
until complete division of the nucleus and cell has been effected. 

Phase I. The first change indicative of beginning karyokinesis, 
according to Flemming, is the formation within the cell-protoplasm of 
two poles opposite to each other and near the nucleus. 

The next change noticed is that in the nucleus : the chromatin 




Fig. 5.— Endothelial, Cells ; Abdomen of Salamander. {Flemming.) 

1. Surface view of nuclear net-work ; A, cell-body ; B, threads of net-work ; C, one of the poles 
with the achromatin threads radiating from it. 2. Equatorial view of a corresponding cell ; A, one of 
the poles; B, the nuclear net-work seen on edge; C, the achromatin threads forming a spindle 
beween the poles. 

threads become plainer, thicker, and more convoluted. This increase of 
chromatin substance is the result of longitudinal splitting of its threads. 
The achromatin layer of the nuclear envelope increases in thickness, 
while the inner layer has become a part of the chromatin net-work. 

Phase II. During this stage the chromatin threads are drawn out 
into loops with long limbs. This arrangement imparts to the looped 
net-work the figure of an aster, or star. 

In the middle of the star is a clear space, which does not stain and 
is occupied by achromatin substance. In animal cells the greater portion 
of the space within the nuclear membrane is filled with chromatin threads, 
while in vegetable cells the achromatin substance predominates. The 
nuclear spindle in the centre of the achromatin substance (Fig. 4, C), 
according to Strassburger and Butsehli, consists of fine, colorless fibres, 



10 



PRINCIPLES OF SURGERY. 



which do not stain at all, or only slightly, by using special nucleus- 
staining reagents, and on this account the achromatin threads probably 
contain no nuclein. 

Phase IIL The star-shaped mass of nuclear threads divides into 
two equal portions, with the angles of the loops to the poles, and their 
limbs partly obliquely, partly perpendicularly to the equator of the 
nucleus. 

The equatorial disk is formed in this manner, and indicates the 
completion of this phase. 

Phase IV. This phase begins with a separation of the threads at the 
equator, and ends with concentration of the threads in each polar segment 
of the cell. 

As the number of loops in each segment is the same as in the old 



-A 

-B 



— C 





Fig. 6.— Epithelial Cell, of Salamander. 

{Flemming.) 

A, pole and achromatin threads ; B, cell-body ; C, disk- 
like arrangement of chromatin threads at equator of nucleus. 



Fig. 7.— Epithelial Cell of Sala- 
mander. (Flemming.) 

A, At, chromatin threads of daughter-stars; 
achromatin threads and pole. 



B 



nucleus, it may be conjectured that the halves of each thread separate 
into the two daughter-stars. 

Phase Y. The threads in the daughter-nucleus form a wreath, after 
which they contract more and more until the undivided convolutions can 
hardly be recognized. 

A nuclear membrane again appears, after which the net-work returns 
to its quiescent state. 

There is a strong tendency at the present time to refer all karyo- 
kinetic changes to the agency of the nucleus, and to ascribe to the proto- 
plasm of the cell the passive role of a nutritive substance. In the 
impregnated ovum the influence of nuclear changes has been described, 
but at the same time it was shown that the protoplasm of the cell is 
capable of automatic as well as responsive action. Pfliiger asserted that 
gravitation is the sole guiding agency in the process of cleavage of 
protoplasm. According to Born, Herturg, Weismann, and K611ikei\the 



KARYOKINESIS. 



11 



protoplasm alone is isotropic, but Whitman thinks that this is far from 
the truth. Others, like Pfliiger, believe that the protoplasm contains 
physiological molecules from which organs are developed. Polarity 
of cell-protoplasm and in nucleus exists independently, and is not recip- 
rocal. Contractions in unfertilized ova have been observed. M. Nuss- 
baum was first to prove that enucleated fragments of an infusorium 
are incapable of reproduction, while parts of an infusorium containing a 
nucleus possessed this power. This would tend to establish the fact that 
the nucleus is indispensable to the preservation of the vegetative energy 
of the cell. On the other hand, 
Gruber, in one of his experiments, 
divided a stentor before fission had 
taken place in such a manner that 
the sections contained no nuclear 
substance, and yet the next day each 
one of these parts represented a 
complete stentor. Against the con- 
clusions drawn from this experiment 
it might be urged that some of the 
nuclear chromatin threads might 
have found their way into the cell- 
protoplasm, and that from them the 
process of reproduction started. 
Nussbaum regards a combination 
of nuclear structure and cell-proto- 
plasm as essential for cell-produc- 
tion. According to Flemming, the 
cell-body begins to divide toward 
the end of the fourth phase of karyo- 
kinesis. Cell-division commences 
with a constriction at the equator, 
which becomes deeper and deeper as 
the daughter-cells assume cell form, 
until complete segmentation takes place. Toward the completion of the 
separation only a few achromatin threads (Fig. 8, B) connect the two. 
To Flemming belongs the credit of having first discovered kaiyokinetic 
changes in cells undergoing division, but our knowledge of this subject 
lias been greatly advanced by the combined labors of Strassburger, 
Arnold, Klebs, and Whitman. Arnold studied this method of cell- 
division in giant cells of the medulla and in the blood-corpuscles of 
leuksemic blood. He preserved the blood-corpuscles in a 6-per-cent. 
methyl-green salt-solution, which preserves cells in a good condition if 




Fig. 8.— Epithelial, Cell of Salaman- 
der. {Flemming.) 

A, A', daughter-glomeruli ; B, achromatin threads still 
uniting the two daughter-cells. 



12 PRINCIPLES OF SURGERY. 

the solution is kept nt a proper temperature in the moist chamber on the 
object-glass. If to this solution a 25-per-cent. solution of chloride of gold 
is added, the kai\yokinetic figures are made clearer. In studying the 
process of karyokinesis in fixed tissue-cells in a state of proliferation, 
it is necessary to resort to the fixation and staining methods described 
by Flemming. The modern observers who have studied regeneration of 
epithelial cells have come to the conclusion that cell-division takes place 
almost exclusively by karyokinesis. Podwyssozki has studied this 
method of cell-reproduction with special reference to regeneration of 
liver-cells, and has come to some very important conclusions. In cats 
and young guinea-pigs he observed, after injury of the liver, extra-nuclear 
chromatin substance before he could detect any karyokinetic figures 
in the nucleus. The chromatin in the cell-body appeared in two forms, — 
either as fine granules scattered diffusely through the protoplasm of the 
cell, or as lumps of chromatin, and he designated these larger masses as 
prochromatin ; but he also noticed that the granular form, at a later stage, 
aggregated and formed masses which united with the nuclear chromatin. 
Klebs explains the presence of chromatin in the cell-protoplasm to an 
extra-cellular origin, — the leucocytes. He believes that the chromatin 
contained in leucocytes is liberated after fragmentation has taken place 
and enters the young cells, where they serve as food and become a part 
of the nuclear net-work. This view is strengthened by the statement of 
Podwyssozki that he found numerous leucocytes in the immediate vicinity 
of the new cells. Ziegler and Obolensky produced arsenical intoxication 
in animals by administering the drug in daily doses subcutaneously, 
and when they examined the liver they found well-marked kai^yokinetic 
figures in the endothelial cells of the intra-acinous capillaries, the epi- 
thelia of the bile-ducts, and, less frequently, in the secreting cells. 
Karyokinetic figures were first visible in the nuclei of the capillary 
endothelia and were undoubtedly caused by the direct action of the 
arsenic upon the cells. These experiments show that karyokinesis will 
follow the application of chemical, as well as traumatic, irritants. 

FRAGMENTATION OF NUCLEUS 

Arnold and Pfitzner have described, in giant and other cells under- 
going pathological changes, direct fragmentary division of the nucleus, 
by which it may break up into many parts, often of unequal size, without 
contemporaneous division of the cell. Arnold and others have also de- 
scribed incomplete fragmentation of the nucleus where the nuclear masses 
remain connected with each other, and can be seen as lobulated and 
reticulated structures. Arnold saw fragmentation of the nucleus in the 
cells of the marrow of bone and in leucocytes undergoing transformation 



DIRECT CELL-DIVISION. 13 

into pus-corpuscles. A nucleus which undergoes fragmentation contains 
but little chromatin substance, and is therefore incapable of multiplica- 
tion by karj^okinesis ; and such cells, according to the investigations of 
Klebs, never take an active part in the regeneration of tissue. 

DIRECT CELL-DIVISION. 

In 1841 Martin Barry first made the observation that the division 
of cells was accompanied with division of the nucleus, and for a long 
time it was believed that this process is simply a segmentation of the 
nucleus, followed by division of the whole cell. Remak taught that 
direct division commenced in the nucleolus, extended to the nucleus, and 
finally resulted in fission of the cell-body, each of the new cells contain- 
ing a daughter-nucleus. 

According to Pfitzner, direct cell-division is a more frequent method 
of cell-multiplication than the indirect in young animals where cell- 
proliferation is rapid. In the embryo the nucleus contains but little 
chromatin, and therefore the karyokinetic figures are less abundant 







Fig. 9. (McKendrick.) 

A, mature cell ; B, commencing division of nucleus and contraction of cell-protoplasm in the centre ; 
C, complete division of nucleus and cell; D, formation of two new cells. 

In most of the regenerative processes in mature tissue-cells repro- 
duction takes place by karyokinesis, and only in exceptional instances 
by direct division. The new cellular elements present karyokinetic 
figures in all stages, and wherever these are seen it is a positive evidence 
that the fixed tissue-cells are the seat of tissue-proliferation, and that 
wounds are healed and defects repaired exclusively by this method of 
cell-formation. 

GRANULATION TISSUE. 

The new cells formed by indirect or direct cell-division in a wounded 
or injured part, the seat of regenerative processes, constitute the granu- 
lation tissue as long as they remain in their embryonal state. As imme- 
diate union never takes place in any part or tissue of the bod}', we are 
forced to admit that every wound heals only by the interposition between 
the divided parts of a greater or less amount of granulation tissue. If 
the wound remain aseptic, and the surfaces of the wound are kept in 
accurate coaptation, the healing is accomplished in a short time, and by 



14 



PRINCIPLES OF SURGERY. 



the production of a minimum amount of new tissue. A similar woun^r, 
with great loss of tissue precluding the possibility of bringing the parts 
in apposition by mechanical resources, must necessarily heal by the pro- 
duction of a large quantity of granulation tissue, the process of repair 
in both instances being the same, the difference being mainly the length 
of time required to complete the healing process and the amount of new 
material necessary for this purpose. In the first case the wound heals 
without visible granulation tissue ; in the latter the defect becomes cov- 
ered with granulations before the wound can heal. The macroscopical 
and microscopical appearances of granulating surfaces are nearly iden- 




Fig. 10.— Granulating Wound. Capillary Loops Surrounded by 
Embryonal Cells. X 300-400. {Billroth- Winiwarter.) 

tical in all the tissues. A bone covered with granulations looks the same 
as a granulating surface of any of the soft tissues. Even the embryonal 
cells of which the granulations are covered, so long as they remain in 
this state, furnish, from their microscopical appearances, only remote or 
no indications as to their histogenetic source and ultimate destination. 
Differentiation takes place during their further development toward the 
completion of the healing process. The bulk of all granulation tissue is 
derived from the connective tissue as this mesoblastic structure is dif- 
fused throughout the entire body, and, with the exception of the nervous 
system, is found in almost every organ. In the nervous system it is 



GRANULATION TISSUE. 



15 



represented b} r an almost similar tissue, — the neuroglia, — which performs 
the same role in the repair of injuries and defects of the brain and 
spinal cord. A wound or defect covered with granulations presents 
a velvety appearance, each, tuft or papilla representing a separate loop or 
net-work of new capillary vessels. 

The new capillary vessels are paved with endothelial cells contain- 




Fig. 11.— Granulation Tissue from Wound. Blood-vessels Injected. X 400. 

(Hamilton.) 
A, A, capillary loops with several branches ; B, ordinary granulation cells ; C, fibroblasts ; D, stroma. 

ing a very large nucleus. Sometimes a single capillary vessel enters a 
papilla and gives off a number of branches, which form a net-work of 
convoluted vessels, rendering the granulations exceedingly vascular and 
liable to bleed on the slightest provocation. 

The blood in the tuft is collected and returned usually through one 
vein. Emigration of leucocytes through the walls of the new capillary 
vessels is a common occurrence, and, when they reach the surface, form 



16 PRINCIPLES OF SURGERY. 

one of the elements of secretion of the wound. When the capillary 
vessels are imperfectly developed, or when they are in a state of in- 
flammation, the exudation becomes profuse and the granulation surface 
becomes covered with a membrane consisting of the products of coagula- 
tion necrosis. Wounds presenting such an appearance have frequently 
been mistaken as an evidence of diphtheritic infection. The so-called 
healthy granulations are small, firm, and of a pinkish-red color, and the sur- 
face from which they spring is only moistened with colorless, viscid fluid. 
Wounds covered with such granulations heal rapidly and leave a small, 
pliable cicatrix. Profuse flabby and pale granulations indicate a want of 
general vitality, or more frequently the presence of pathogenic microbes, 
which act injuriously upon the process of transition of embrj^onal cells 
into tissue of a higher type. Such granulations are frequently met with 
in wounds after imperfect operations for tubercular lesions, in suppurat- 
ing wounds and in" ulcers of the lower extremities, where the vascular 
conditions are unfavorable for the growth and development of new tissue. 
Histologically granulation tissue is composed of a delicate, cedematous 
reticulum, and upon its fibres can be seen numerous connective-tissue 
corpuscles. The reticulum is intimately connected with the blood-vessels, 
and in its meshes are contained the embryonal cells and leucocytes, the 
latter serving as food for the former. The embryonal connective-tissue 
cells are about two or three times larger than the leucocytes. The giant 
cells which are occasionally found are fibroblasts which have grown to 
such enormous proportions by inclusion of nutritive material derived 
from disintegrating leucocytes. 

VASCULARIZATION OF GRANULATION TISSUE. 

The vessels which furnish the blood-supply to the granulation 
tissue are new structures, and are usually formed from pre-existing 
vessels in injured vascular tissue, and from the nearest blood-vessels in 
non-vascular tissue. Yessel formation and tissue proliferation are 
initiated simultaneously, and keep pace with each other until the neces- 
sary amount of granulation tissue has been produced, when, during the 
transformation of the embr} T onal cells into permanent tissue, the vascular 
supply is gradually diminished b}^ the obliteration and disappearance of 
all of the superfluous vessels. As the la} r er of granulation tissue seldom 
exceeds more than J- inch in thickness, the new vessels always remain 
short, and retain their communication with the pre-existing vessels from 
which they started. Travers, in his experiments on injuries of the frog's 
web, has observed that the blood in the divided vessels becomes stagnant 
some little distance from the wound. During this time material oozes 
from the cut vessels, which constitutes the primary-wound secretion. 



VASCULARIZATION OF GRANULATION TISSUE. 



17 



Before granulations can be established the circulation must become 
restored by enlargement and multiplication of preformed vessels. 

The capillary vessels which have been cut or otherwise injured are 
closed with nature's haemostatic — a minute thrombus. The intra-vascular 
pressure on the proximal side of the obstruction results in dilatation of 
the vessel, which produces an increased blood-supply to the part com- 
mensurate with the increased demand for nutritive material. The new 
blood-vessels are formed by angioblasts, which are proliferated from pre- 
existing vascular structures. Arnold has studied the formation of new 
blood-vessels in the stump of the tail of tadpoles after amputation, and 




Fig. 12.— Superficial Capillaries of a Wound Beginning to Granulate, about 
Forty-eight Hours after its Infliction, x 350. (Hamilton.) 

A, free surface ; B, the capillary loops all distended with blood, and being driven outward in tortuous 

festoons ; C, embryonal cells. 



in keratitis vasculosa artificially produced in the cornea of rabbits. To 
the researches of this author we owe most of the knowledge we possess 
on this subject. The new vessels are produced by the budding process 
from capillaries near the surface of the wound. The bud appears first 
as a circumscribed thickening of the capillary wall, which soon projects 
outward in the form of a triangular cellular mass composed of angio- 
blasts. The bud is then transformed into a long string, terminating in 
a delicate granular thread. 

The base of such a projection becomes excavated, and blood enters 
from the vessel to which it is attached. When the terminal ends of two 

2 



18 



PRINCIPLES OF SURGERY. 



of such projections meet they unite and form an arch, which, after they 
have become permeable to the blood-current, constitute a capillary loop 
from which branches again may develop in the same manner. The new 
channels contain, upon their inner surfaces, nuclei at variable distances, 
which subsequently undergo transformation into endothelial cells. The 
adventitia is formed by round cells, which arrange themselves along the 
outer surface of the new channels. Hunter maintained that blood- 
vessels are formed in granulations independently of pre-existing vessels, 
in the same manner as in the embryo, and that they enter into commu- 
nication with the vascular S3^stem subsequently. Such a method of 
vascularization during post-embryonic life is not proved. A number of 
pathologists, and among them Billroth, still believe that blood-corpuscles 
and blood-vessels can be produced from connective tissue. They claim 
that connective-tissue cells in the intercapillary spaces enlarge, become 
branched, and that by union between similar projections between two or 




Fig. 13.— Formation of New Blood-vessels by Budding. (Arnold.) 

A, after three hours ; B, after six hours. 

more cells hollow spaces are created which serve as blood-vessels, while 
the nucleus assumes the role of a hsemapoietic organ, — a process which is 
well illustrated by Fig. 14. 

Still another method of vessel formation in granulations has been 
observed and described by Travers. He noticed that, when one of the 
new capillary vessels ruptures and blood is poured out into the granula- 
tion tissue, among the embryonal cells a vascular space without walls is 
formed. The extravasated blood, under these circumstances, did not 
disintegrate, and as soon as the space came in contact with another 
capillary loop the wall gave way and a communication was established 
between the two capillaiy vessels, and later the channel became lined 
with endothelial cells. This method of vessel formation is termed 
canalization. While the possibility of the development of new vessels 
independently of preformed blood-vessels cannot be denied, such an 
origin is, to say the least, exceedingly rare, and for all practical purposes, 



CICATRIZATION. 



19 



when we speak of vascularization of granulation tissue or the formation 
of new blood-vessels in general, we mean the formation of new channels 
by tissue proliferation from the walls of pre-existing blood-vessels. 
D. J. Hamilton, author of the excellent " Text-Book of Pathology," 
asserts that the blood-vessels in granulation tissue are not new, but 
dilated, tortuous, preformed vessels. 

In wounds that heal rapidly the existence of most of the new blood- 
vessels is a short one. With the beginning of cicatrization they 
disappear rapidly, and comparatively 
only a few of them remain as per- 
manent structures as a S3 T stem of 
collateral vessels which restore indi- 
rectly the loss of continuity between 
the divided vessels. A failure of the 
vessels to disappear after cicatrization 
has been completed usually is an indi- 
cation that some pathogenic micro- 
organisms have become embedded in 
the scar-tissue, which interfere with 
the proper and prompt transformation 
of embryonal into permanent tissue. 
Such scars are often met with after 
operations for tubercular lesions and 
after the healing of extensive burns, 
being caused in the first instance by 
the bacillus of tuberculosis and in the 
latter by pus-microbes. The vascular 
conditions in granulating surfaces 
should be carefully studied, and in 
the treatment due attention should 
be given to this important point, as 
compression and position are potent 
measures in improving a faulty circulation, which may have indefinitely 
retarded the healing process. 




Fig. 14.— Development of Blood- 
corpuscles in Connective-tissue 
Cells, and Transformation of the 
Latter into Capillary Blood-ves- 
sels. {Fluegge.) 

A, an elongated cell ■with a cavity in its protoplasm 
occupied by fluid and by blood-corpuscles ; B, a hollow 
cell, the nucleus of which has been multiplied : the new 
nuclei are arranged around the wall of the cavity, the 
corpuscles in which have now become discoid ; C, shows 
the mode of union of a " hasmapoietic " cell, which, in 
this instance, contains only one corpxiscle, with the 
prolongation (BL) of a previously existing vessel. 
A, and C, from the newborn rat ; B, from foetal sheep. 



CICATRIZATION. 

The process of transformation of the embryonal cells in granulation 
tissue into permanent, fixed tissue-cells is called cicatrization. Sir James 
Paget has well said that during the stage of the healing process a life of 
eminence is changed into one of longevity. In tissues endowed with 
great vegetative powers and a high degree of adaptation, even large 
defects are replaced by tissue which resembles to perfection, anatomi- 



20 



PRINCIPLES OF SURGERY. 



cally, Histologically, and physiologically, the injured pre-existing tissue. 
This is the case in injuries involving considerable loss of substance in 
















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bone, tendons, and peripheral nerves. Complete restoration of a 
peripheral nerve frequently takes place after resection of more than an 



CICATRIZATION. 



21 



inch of its continuity. In subcutaneous tenotomy the tendon-ends may 
be kept separated for two or more inches, and yet after a few months it 
would be difficult to ascertain, even after the most careful examination, 
the site of operation. The fractured ends of a broken bone may be 
completely separated b}^ lateral displacement during the entire time 
required in the healing process, and yet they are firmly united by the 
interposition of a connecting bridge of new bone. In other tissues 
endowed with less reparative energy, as for instance the muscular fibre, 
a slight separation results in the formation of cicatricial tissue between 
the anatomical structure which it is the intention to unite. By cicatri- 
zation is therefore understood the completion of the reparative process, 
and the term does not necessarily imply the formation of a permanent 
cicatrix. An ideal healing culminates 
in the formation of tissue which effects 
a physiological restitution of a defect 
caused by injury or disease. As a rule, 
it can be stated that the result will 
be satisfactory in proportion to the 
amount of granulation tissue produced 
or required in the process of repair. 
In an aseptic wound the reparative 
material will not be in excess of the 
local demand, and the demand will 
depend on the degree of accuracy of 
approximation of the surfaces of the 
wound. Cicatrization begins in the 
ganulation tissue nearest the pre- 
formed vessels ; that is, the margins 
and surface of the wound. 

The embryonal connective-tissue cells, or fibroblasts, as they are 
called, at first round, become elongated with thread-like prolongations 
from the extremities. (Fig. 16.) 

The new connective tissue contracts, thus bringing the margins of 
the wound or granulating surface in closer apposition, and by its 
constricting effect assisting in the obliteration of superfluous vessels. 
The cicatrix or scar will be large if the process of granulation has been 
in excess of the demand, or if a large defect had to be healed by the 
deposition or interposition of a large quantity of cicatricial material. 
Large scars should be prevented, if possible, by appropriate treatment, 
as from the contraction they give rise to distressing deformities, and 
from their low vitality they furnish a permanent predisposition to ulcer- 
ative processes and not infrequently become the seat of malignant 




Fig. 16.— Embryonal Connective- 
tissue Cell Undergoing Transfor- 
mation into Mature State. (Ziegler.) 

A, the cell-body; still contains a considerable 
amount of protoplasm, which, however, gradually di- 
minishes toward D, where it represents a mature 
connective-tissue cell with a very small amount of 
protoplasm surrounded by connective-tissue fibres. 



22 



PRINCIPLES OF SURGERY. 



disease. After the healing of any ulcer of considerable size upon the 
mucous surface of any of the hollow viscera the cicatricial contraction 
often gives rise to the formation of strictures. Nerves appear to form 
in granulations, as these are often exceedingly tender to the touch. 
Their existence, however, has not been demonstrated. The pain and 
tenderness may be caused by force being transmitted to subjacent nerves. 
According to Van der Kolk, no lymphatic vessels are present in granula- 
tion tissue. During the process of cicatrization all the embryonal cell- 
elements undergo transformation into mature tissue, the fibroblasts are 
converted into connective tissue, the angioblasts into vessels, the 
mj'oblasts into muscle-fibres, the osteoblasts into bone, etc., each histo- 
logical element represented in the wound or defect furnishing the 

material for its own repair. 



EPIDERMIZATION. 

A wound of the external sur- 
face of the body can be said to have 
healed after the completion of epi- 
dermization. In accordance with 
the general law of succession of 
cells, epidermization takes place ex- 
clusively by proliferation of pre- 
formed epithelial cells. The new 
epithelial cells have a more or less 
rounded shape, and cover the granu- 
lations from the margins of the 
wound, where the new skin appears 
as a bluish-pink pellicle. At first 




Fig. 17.— Wandering Epithelial Cells 
from Frog. (Klebs.) 



a, old epithelial ceiis upon edge of wound of skin, with thev do not readily adhere to the 

proliferation of nucleus. J J 

granulations, but appear to cover 
them (Fig. 15, E') ; later, however, they throw down long processes which 
penetrate the granulations, and in this way obtain a permanent foothold. 
New epithelial cells possess amoeboid movements, may become detached 
from the epithelial matrix, and wander some distance and form perma- 
nent attachments, and in such an event an independent centre of epider- 
mization is established. Migration of epithelial cells was first observed 
and described by Klebs in superficial wounds in the skin of the frog. 
(Fig. 17.) The irregular projections of the new skin over the granula- 
tions, so frequently observed during the healing of wounds by granulation, 
is undoubtedly often due to such a displacement of embryonal epithelial 
cells. In granulating surfaces following destruction of the skin by burns, 
caustics, or ulceration, independent centres of epidermization are often 



POSITIVE INDICATIONS IN THE TREATMENT OF WOUNDS. 23 

seen in the midst of the field of granulations. In such cases the entire 
thickness of the skin at some points has not been destroyed, and epi- 
thelial proliferation takes place from remaining remnants of glands, as 
is well shown at F and G in Fig. 15. The granulations in the immediate 
vicinity of the zone of epidermization become reduced in size, the blood- 
vessels are diminished in number, and the subjacent fibroblasts are 
rapidly converted into connective tissue. In wounds of the skin which 
heal without visible granulations the papillae are absent from the cicatrix, 
even although it be broad from subsequent 3delding to traction. In 
wounds healing by open granulations new papillae are formed in the new 
skin, because the capillary loops atrophy downward and become the 
papillary vessels. Epidermization and cicatrization are favorably influ- 
enced by measures which secure for the wound an aseptic condition 
throughout, and by keeping the delicate granulations covered with pro- 
tective silk until the wound is completely healed. 

POSITIVE INDICATIONS IN THE TREATMENT OF WOUNDS, WITH SPECIAL 
REFERENCE TO SECURE UNION BY FIRST INTENTION. 

Absolute Asepsis. — Absolute asepsis can only be secured by strictest 
antiseptic measures. Surgical cleanliness is more than ordinary clean- 
liness. 

Antiseptic precautions are employed for the purpose of securing for 
the wound and everything that is brought in contact with it an aseptic 
condition. The term antiseptic, used as a noun, should be restricted to 
agents which retard the growth of pathogenic germs, in contrast with the 
term germicide, which is applied to agents which destroy pathogenic mi- 
crobes. A solution of corrosive sublimate, when introduced into a culture 
solution in the proportion of 1 to 300,000 will restrain the development of 
anthrax spores ; but to insure the destruction of these spores a solution of 
1 to 1000 must be used. The mechanical removal of microbes from the field 
of operation by shaving and washing with warm water and potash-soap 
should be as thorough as possible, but cannot be relied upon in securing 
asepsis. The surface must be disinfected with a reliable germicidal solu- 
tion, either a l-to-1000 solution of corrosive sublimate or a 4-per-cent. solu- 
tion of carbolic acid. Accidental wounds must always be considered as 
infected wounds, and a faithful effort must be made to render them 
aseptic by exposing, if possible, the entire wounded surface to the direct 
action of one of these solutions, while the surface for a considerable dis- 
tance around it is also disinfected. Recently, a weak solution of the 
double cyanide of mercury and zinc has been recommended by Sir Joseph 
Lister as an antiseptic, and, from his experimental investigations and 
clinical experience, it appears that this substance possesses an advantage 



24 PRINCIPLES OF SURGERY. 

over carbolic acid, corrosive sublimate, and other antiseptics, as it exerts 
an inhibitory effect upon microbes which still may remain in the wound 
or its immediate vicinity, which prevents them from multiplying in the 
tissues or in the dressing. Fuerbringer recommends the following proced- 
ure for the disinfection of the hands : 1. Remove all visible dirt from be- 
neath and around the nails. 2. Brush the spaces beneath the nails with 
soap and hot water for a minute. 3. Wash for a minute in alcohol, and, 
before this evaporates, in the following solution : 4. Wash thoroughly for 
a minute in a solution containing 1 to 500 of corrosive sublimate or 3 per 
cent, of carbolic acid. On each side of the wound or field of operation a 
towel wrung out of an antiseptic solution is spread smoothly, in order 
that, during the operation, instruments and sponges will not be contam- 
inated by being brought in contact with non-aseptic clothing or surface. 
None but sterilized sponges are to be used, and, in the absence of such, 
pieces of aseptic gauze folded into convenient shape should be used as 
substitutes. The cheapest and most reliable method of disinfection of 
instruments is to boil them for five minutes in a 1-per-cent. solution 
of carbonate of socla, and then place them upon an aseptic towel, ready 
for use. If these antiseptic precautions have been faithfully carried 
out, sterilized water can be used for irrigation during the operation, 
or the dry method of operating recently introduced into practice by 
Landerer can be followed in operating upon aseptic tissues or in the 
treatment of aseptic wounds. In the operative treatment of suppurative 
affections, irrigation with a l-to-5000 solution of sublimate must be fre- 
quently resorted to during the operation, and, in the removal of tubercu- 
lar products, irrigation with an aqueous solution of the tincture of 
iodine, made by adding enough of the tincture to sterilized water to 
impart to the solution a sherry color, should be used. 

CAREFUL H^EMOSTASIS. 

The presence of a blood-clot between the surfaces of the wound is 
objectionable for the following reasons: 1. It separates mechanically the 
surfaces which it is intended to unite. 2. It serves as a culture medium 
for microorganisms which, if in contact with living tissue, might remain 
harmless. 3. It gives rise to tension, and consequently becomes pro- 
ductive of pain and an undue degree of reflex irritation. For years, von 
Bergmann has insisted that careful arrest of haemorrhage is one of the 
most urgent and important indications in the treatment of wounds, and 
his teachings merit the attention of every prudent surgeon. Bleeding 
points should be tied with sterilized catgut or silk. A number of sur- 
geons have discarded catgut, as it is more difficult to render it aseptic 
than silk. The latter can be readily sterilized by boiling. The hsemor- 



ACCURATE SUTURING. 25 

rhage that so often interferes with an ideal healing of the wound is the 
capillary or parenchymatous oozing, and this should always be carefully 
arrested before the wound is sutured. The following measures should be 
resorted to in controlling this form of bleeding, and in the order named : 
1. Position. 2. Surface compression. 3. Hot-water irrigation. 4. Anti- 
septic tampon. 

1. In wounds of the extremities, capillary oozing is usually promptly 
arrested by holding the limb in a perpendicular position. In this position 
the intra-arterial pressure is diminished and the return of venous blood 
favored, both of which are important elements in diminishing the amount 
of blood in the capillary vessels. In order to produce the desired effect, 
this position should be maintained for fifteen to twenty minutes, and 
the limb should be kept elevated for at least six hours after the 
operation. 

2. Surface pressure with a flat sponge or a compress mechanically 
arrests the bleeding, and the capillary vessels, partly or completely 
emptied of blood, are placed in a more favorable condition for the forma- 
tion of a thrombus. After an amputation, for instance, the sponge or 
compress is applied to the surface of the cut muscles and the flaps are 
laid over it, and compression with two hands applied, with the limb in 
a perpendicular position before the elastic constrictor is removed. Com- 
pression, continued in this manner for ten or fifteen minutes, will usuall3 r 
be successful in completely arresting parenchymatous bleeding. 

3. Irrigation with water at a temperature sufficiently high to coagu- 
late the albumen on the surface of the wound seals mechanically the cut 
vessels, and, at the same time, produces a localized anaemia' by contract- 
ing the terminal arterial branches. A temperature of 120° F. will 
answer for this purpose. 

4. Styptics should never be employed in arresting bleeding from a 
recent wound. If the procedures mentioned fail in accomplishing the 
desired object, the wound should not be sutured until haemorrhage has 
been completely checked by the use of the antiseptic tampon. The 
wound is packed with iodoform gauze, and the customary dressing is 
applied in such a manner as to exercise uniform gentle pressure. After 
twenty-four hours the dressing and tampon are removed, and the wound 
closed with sutures. In such cases secondary suturing is of great value 
in securing a speedy and satisfactory healing of the wound. 

ACCURATE SUTURING. 

Brilliant operators are not always the best surgeons. The best results 
in surgery follow the one who is most painstaking in following out the 
minutest details. This assertion applies most forcibly in the treatment 



26 PRINCIPLES OF SURGERY. 

of wounds. The surgeon here occupies the position of handmaid to the 
vis medicatrix naturae, and in the exercise of his duties must do all in 
his power to tax only to a minimum extent the regenerative resources 
of the wounded tissues. In the treatment of wounds it becomes his 
imperative duty not only to unite the surfaces of the wound accurately 
and neatly, but to unite, whenever it becomes necessaiy, tissues of the 
same anatomical structure and physiological function. Divided nerves, 
tendons, muscles, fascia, must be separately united with absorbable buried 
sutures before the wound is closed by the ordinary interrupted or con- 
tinuous suture. When several nerves or tendons have been divided in 
the same wound, great care must be exercised to unite the ends of the 
same nerve or tendon. Accurate approximation of a deep wound is im- 
possible without the buried suture. Several rows. of these sutures may 
be required. Reliable catgut should be preferred for the deep sutures, 
but if this material is not at hand fine silk can be used. The best ma- 
terials for the ordinary interrupted sutures are silk or silk-worm gut. 
Separate sutures for the skin are usually required in order to approximate 
the superficial margins of the wound accurately, and for this purpose 
horse-hair is the most desirable material. If the surgeon has reason to 
believe that the wound is aseptic, drainage should be dispensed with, 
because the manner of suturing, as just described, guards against the 
occurrence of " dead spaces." An absorbent antiseptic compress, com- 
posed of a few layers of iodoform gauze and a thick layer of salicylated 
cotton, or sublimated moss or wood-wool, is the most appropriate dress- 
ing for such cases. The bandage to retain this dressing is applied in 
such manner as to exercise uniform equable compression, — an important 
element in affording support to the injured vessels and in securing rest 
for the parts involved in the injury. 

PHYSIOLOGICAL REST. 

In the after-treatment of a wound nothing is more important than 
to secure for the parts which have been mechanically united, as far as 
possible, physiological rest. The importance of rest in the prevention 
and treatment of inflammation has been prominently brought forward 
by Hilton, and his teachings have resulted in a great deal of good in the 
treatment of inflammatory surgical affections. If one of the extremities 
is the seat of the wound, immobilization upon a splint or with a plaster- 
of-Paris dressing, in such a position as to relax the muscles involved in 
the wound, is of paramount importance. The injured part must be kept 
in a position which will favor a normal blood-supply and prevent passive 
hyperemia. A wound properly dressed should not be disturbed until 
union has taken place. If any one of the three most important indica- 



UNION BY SECONDARY INTENTION. 27 

tions for a change of dressing — pain, rise in temperature, and saturation 
of the dressing with wound-secretions — do not arise, the first dressing is 
allowed to remain for eight days to six weeks, according to the location, 
character, or size of the wound. In wounds of the gastro-intestinal 
canal physiological rest is secured by abstinence from food, and, if 
necessar}^, peristalsis is diminished by a few doses of opium. In wounds 
of the bladder distention of the organ is prevented by the introduction 
and retention of a catheter. In wounds of the brain or its envelopes 
rest is secured by exclusion of light and by enforcing quietude in the 
patient's room. 

UNION BY SECONDARY INTENTION. 

In an aseptic wound all the new material resulting from proliferation 
Of the fixed tissue-cells is used in the process of repair, and the time for 
healing of the wound will depend on the anatomical structure of the 
part injured and the amount of material required to form a bridge of 
living tissue between the divided parts. As long as the wound heals 
without destruction of any of the new tissue-elements by specific 
microbic causes, it is proper to speak of a union by primary intention, 
whether the healing is completed in three or four days or whether it is 
protracted for months until the ultimate object of wound treatment has 
been reached. From a pathological, and even from a practical, stand- 
point, it is not correct to include, under the head of healing by the 
second intention, aseptic wounds that, on account of want of proper 
approximation, or on account of loss of tissue, have of necessity to heal 
by granulation, with infected wounds in which the regenerative processes 
are disturbed by suppuration. In a suppurating wound the embryonal 
cells which are destined to become transformed into new tissue are 
exposed to the destructive action of pus-microbes and their ptomaines, 
their protoplasm is destroyed, and they become one of the histological 
sources of pus-corpuscles. The cells on the surface of the wound, being 
most distant from the vascular supply, possess the least power of resist- 
ance to the action of pus-microbes, and on this account, as well as from 
the greater number of pus-microbes on the surface of the wound than in 
the deeper tissues, they are converted into pus-corpuscles. As long as 
suppuration remains active the superficial layer of granulation cells are 
destroyed, and as soon as other embryonal cells take their place the 
process is repeated, and thus the healing of the wound is indefinitely 
delayed. 

When a favorable change takes place in the wound, either spon- 
taneously or from the emplo3^ment of antiseptic measures, suppura- 
tion is diminished, the granulations become firmer and more vascular, 



28 PRINCIPLES OF SURGERY. 

and cicatrization and epidermization now progress in a satisfactory 
manner. Such a favorable change in the condition of the wound can be 
readily explained after the use of such agents as are known to destroy 
the microbic cause of the suppuration when brought in contact with the 
wound. In such a case we would naturally expect that, with the removal, 
destruction, or rendering inert of the pus-microbes, the embryonal cells 
would remain attached to the point where they were produced, and would 
soon be converted into tissue resembling the matrix which produced 
them. Spontaneous cessation of suppuration, and with it the conversion 
of a surface covered with dead material into a health}', granulating sur- 
face, would indicate either that the virulence of the pus-microbes had 
become attenuated, that the soil was no longer congenial for their multi- 
plication, or finally that the resistance on the part of the tissues to their 
pathogenic action had become increased. That tissue resistance has a 
potent influence in neutralizing and modifying the action of pathogenic 
microorganisms has been observed clinicallj' and demonstrated experi- 
mentally. Suppurating wounds are graver atfections, and are more dif- 
ficult to manage in the aged and in badly-nourished persons, as well as in 
patients debilitated from all kinds of excesses and other protracted dis- 
eases. A good circulation of the part is an important element in counter- 
acting the cause of suppuration. A chronic varicose ulcer of the leg 
that suppurates freePy, as long as the patient continues to use the limb, 
is often transformed into a healthy granulation surface after a few days 
of rest in bed with the affected limb in an elevated position. 

TREATMENT OF SUPPURATING WOUNDS, WITH SPECIAL REFERENCE 
TO HASTENING THE PROCESS OF REPAIR. 

In the treatment of an accidental wound, which alwa} r s must be 
regarded as a septic wound, or in the management of a wound where the 
antiseptic precautions have failed, no time should be lost in securing for 
the wound and its vicinit}^ an aseptic condition by thorough disinfection. 
The surroundings of the wound are disinfected in the same manner as 
for an operation. The wound is exposed as thoroughly as possible to 
direct treatment by enlarging it over recesses otherwise inaccessible, 
after which it is thoroughly irrigated with a solution of sublimate (1 to 
2000). If the granulations are copious and flabby they must be removed 
with Yolkmann's sharp spoon, and after the bleeding has ceased a 
12-per-cent. solution of chloride of zinc is applied ; after a few minutes 
the surplus fluid is washed away by irrigation with the sublimate solu- 
tion. The wound is now dried, sutured, and drained. Drainage in 
these cases is a necessary evil, as the surgeon can never feel certain that 
he has succeeded in obtaining perfect asepsis. If the wound is extensive, 



SUTURING OF GRANULATING WOUNDS. 29 

or if pus has been burrowing in different directions along the deep 
tissues, as in cases of compound fracture where a thorough disinfection 
of every part of the wound, as already described, is impossible or im- 
practicable, constant irrigation with a saturated solution of acetate of 
aluminum should be instituted and continued until the wound has been 
rendered aseptic. Acetate of aluminum is a reliable antiseptic, is non- 
toxic, and penetrates the tissues deeply. The treatment most appro- 
priate for a recent aseptic wound is to be adopted as soon as suppuration 
has ceased and the general symptoms at the same time point to an 
aseptic condition. 

SUTURING OF GRANULATING WOUNDS. 

If union by primary intention has failed to take place, for any reason, 
in wounds which can be closed by suturing, a second attempt can be 
made to approximate the surfaces with sutures, with fair prospects of 
success as soon as the granulations are in an aseptic condition. Aseptic 
granulating surfaces when brought in contact unite rapidly, as vascular 
connections between the new capillary loops are established in a remark- 
ably short time, and the wound then heals in the same manner as after 
primary suturing. The cases best adapted for secondary suturing are 
those where suppuration has ceased, the granulations have become small 
and firm, — in short, wounds in which cicatrization has commenced. The 
technique in the treatment of such wounds is the same as in cases of 
aseptic recent wounds. The advantages of this method of dealing with 
wounds that have failed to unite are pronounced when the wound is deep 
and the margins can be coaptated without much tension. Buried sutures 
can be used for the same purpose and with the same benefit as in the 
treatment of recent wounds. Before the surfaces are brought in contact 
with the sutures it is important to disinfect and dry the granulations 
thoroughly. As secondar} 7 suturing is applicable only in the treatment 
of such wounds where w r e have every reason to assume that an aseptic 
condition exists or can be secured by disinfection, the whole wound 
should be carefully closed and drainage must be dispensed with, in order 
to obtain rapid healing of the entire wound. It has been recently 
suggested by Hahn that in extensive defects of the skin a covering for 
the wound can be obtained \>y sliding of the skin, after undermining it for 
some distance, in a direction most suitable. That this procedure is 
applicable only under circumstances when the surgeon is sure of asepsis 
is to be taken for granted, as otherwise it might be followed by gangrene 
and still greater loss of tissue. 



CHAPTER II. 

Regeneration of Different Tissues. 

In connection with the subject of healing of wounds it is very 
important for the student to familiarize himself with the vegetative 
capacity of the different tissues of the body in order to estimate with 
some degree of accuracy the part taken by each tissue in the reparative 
processes which take place after an injury or disease. No positive proof 
has yet been furnished that the leucocytes or any other of the cellular 
elements of the blood take any active part in the restoration of lost parts. 
It does not appear to me reasonable or logical that such an indifferent 
cell as the leucocyte should ever become transformed directly into a 
fixed tissue-cell, and it is still more improbable that it should be 
possessed with such a diverse vegetative capacity as to undergo a transi- 
tion in one place into a connective-tissue cell, in another into bone, and 
still another into a muscle-fibre. It is much more rational to assume, 
in the repair of an injury and in the regeneration of a part destroyed 
by disease, that the universal law of legitimate succession of cells asserts 
itself, according to which the reparative process is initiated and completed 
by homologous cell proliferation. 

In the following pages experimental and clinical proofs will be 
advanced which will at least tend to establish the truth of this assertion. 

NON-VASCULAR TISSUE. 

The part taken by blood-vessels in regenerative processes is well 
shown in the healing of wounds of non-vascular tissue. Large wounds 
of the cornea and cartilage can only heal after a blood-supply has been 
established through new vessels from the nearest vascular district. 
Rapid vascularization of the non-vascular tissues is always observed 
when the wound has become infected. 

Cornea. — The normal cornea contains no blood-vessels, but vascular 
spaces, which form a S3 T stem of channels for the circulation of the plasma- 
fluid. In 1863 Recklinghausen discovered in these spaces migrating 
corpuscles, resembling in size and shape the white blood-corpuscle, which 
he regarded as offsprings of the corneal corpuscles. Later, Cohnheim 
showed that these wandering cells were leucocj'tes which had escaped 
from the pericorneal capillary vessels and had found their way into these 

(30) 



NON- VASCULAR TISSUE. 31 

channels. In traumatic keratitis these spaces become blocked with 
leucocytes, and they constitute largely the primary product of inflam- 
matory exudation long before the fixed cells of the cornea could have 
yielded such an amount of cellular elements. Strube and His studied 
experimentally the healing of wounds of the cornea and traumatic kera- 
titis. They injured the cornea of rabbits by cutting and cauterization. 
As the cornea is freely supplied with nerves, they observed as one of the 
earliest tissue changes a reflex paretic dilatation of the marginal blood- 
vessels. The marginal hyperemia was followed by the formation of new 
blood-vessels in the direction of the seat of injuiy. The early opachy 
around the wound and the space between the wound and the advancing 
channels are caused by the presence of leucocytes in the vascular spaces ; 
later, to proliferation of the corneal corpuscles. That leucocytes enter 
the plasma-canals when the cornea is irritated has been definitely settled 
by Cohnheim by one of his most ingenious experiments. He injected 
finely-divided carmine suspended in an acid, or precipitated aniline into 
the dorsal lymph-sacs of frogs, with the result that when he irritated 
the cornea, a few da}^s later, leucocytes stained with the pigment-material 
appeared at the margin of the cornea where cell-migration was known to 
appear first. He found a rapid increase of corneal corpuscles in the 
animal subjected to experimentation ; thus, in one instance, eighteen 
hours after the injury, he found, in spaces normally occupied by one 
corpuscle, as many as 20 to 30 j f oung cells closely packed together. 

D. J. Hamilton regards as the first change in an irritated cornea an 
increase of the plasma-current which may destroy the endothelial lining 
of the canals, and according to this observer cell-migration into the 
corneal spaces occurs later. Unimpaired innervation of the cornea is 
an important factor in the prompt healing of wounds of this structure, 
as it is well known that in patients suffering from glaucoma, and in the 
aged, wounds of the cornea heal often in a very unsatisfactory manner. 
An aseptic wound of a normal cornea heals without opacity ; the new 
corneal corpuscles, after they attain maturity, transmit light as perfectly 
as the cells from which they are produced. Imperfect restoration of 
tissue is to be expected when the regenerative process is complicated by 
a suppurative inflammation with considerable destruction of tissue. 
Gussenbauer incised the cornea in rabbits half-way between the centre 
and its margin to the extent of half a line to a line, and found, in exam- 
ining the specimens after twenty-four hours, that no union had taken 
place. The wound-surfaces at this time were glued together by an inter- 
posed substance. The surfaces of the wound were in close contact 
at a point corresponding to the middle portion of the cornea, and the 
gap widened toward each of its surfaces so that the temporary cement- 



32 



PRINCIPLES OF SURGERY. 



substance represented two cones with their apices directed toward each 
other and the bases toward the surfaces. On staining the specimens 
with chloride of gold it was found that this substance contained cells 
which were most numerous toward the surfaces of the cornea. The cor- 
neal corpuscles on the cut surfaces were seen to be enlarged and presenting 
different stages of cell-division. Instead of round the corpuscles were 
spindle-shaped, some containing one nucleus, others two nuclei ; intercellu- 
lar substance granular. In specimens eight days old the space between the 
cut surfaces was occupied almost exclusively by new corneal corpuscles, 
and the edges of the wound could no longer be clearly denned. During 
cicatrization of the wound the number of cells is diminished, while in 
form and size they resemble more and more the mature corneal corpuscles 
from which they were derived. 

In a non-penetrating incised wound of the cornea the gap is filled 




Fig. 18.— Corneal Corpuscles in a State of Proliferation. (Sen/tleben.) 

A, old corneal corpuscles with one or two nuclei and young offshoots, B and C. 



up after a few days with young cells derived from the cj r lindrical cells 
of the deepest laj^er of the corneal epithelia. 

If the wound has penetrated, the posterior third of the wound gaps 
toward the anterior chamber of the eye, and is first plugged with the 
products of coagulation necrosis, which is later replaced by epithelial 
cells from the membrana Descemeti (Fig. 19, C), while the anterior por- 
tion is occupied by epithelial cells the same as in the non-penetrating 
wounds. At the end of the first week the corneal corpuscles begin to 
proliferate, and the cells from this source gradually displace the epithe- 
lial cells and bring about the definitive healing of the wound. As wounds 
of the cornea are not sutured, the surgeon should aim to secure approxi- 
mation by removing coagulated blood if present, and Ivy correcting any dis- 
placements which ma}' be present by direct measures, and finally b} T apply- 
ing a dressing which will exert uniform and equable elastic compression. 



NON-VASCULAR TISSUE. 



33 



Although the antiseptic treatment cannot be carried out with the same 
precision in the treatment of wounds of the cornea as in other localities, 
it is at least the duty of the surgeon to use only sterilized instruments 
and aseptic sponges, and to employ such mild antiseptic solutions as will 
at least exercise an inhibitory influence upon pathogenic microorganisms 
that may be present in the wound or upon the surface of the eye. 

Cartilage. — Cartilage is in every sense of the word a non-vascular struc- 
ture, as even the plasma-channels found in the cornea are absent here. 
Plasma diffusion must take place between or through the cells. It is un- 




Fig. 19.— Wound of Cornea, (von Wyss.) 
A-A', new corneal corpuscles ; B-A', temporary plug of fibrin ; C, epithelia from membrana Descemeti. 

doubtedly on account of the limited provisions for nutritive supply that the 
vegetative capacity of this tissue is so exceedingly low. Normal cartilage 
when injured is unable to repair the defect. The process of healing of 
wounds of cartilage was first studied experimentally by Redfern. In 
one experiment he found the wound almost unchanged after twenty-nine 
days. In one specimen, where the healing process had been completed, 
he found the defect repaired by connective tissue. The microscopical 
description of the healing process corresponded with that given by 
Goodsir of inflammatory processes in this structure. Along the margins 

3 



34 PRINCIPLES OF SURGERY. 

of the wound the cartilage-cells multiply and the cement-substance is 
dissolved. No new cartilage-cells are produced, and the space is occu- 
pied by connective tissue. Vascularization toward the seat of injury 
from the marginal vessels of the perichondrium takes place in the same 
manner as in the cornea. Reitz traced the formation of connective tissue 
from the cartilage-cells in tracheotomy wounds in rabbits. He observed, 
after the cement-substance had become dissolved, that the cartilage-cells 
were transformed into spindle-cells, and later into connective tissue. He 
found the gap between the divided cartilage-ring filled with such cells a 
few days after the wound had been inflicted, and explains the discrep- 
ancy between the results he obtained and those described by Redfern on 
the ground of the close proximity of vascular supply in his case and the 
remoteness of vessels from the wound studied by Redfern, as the latter 
experimented on articular cartilage. Gussenbauer studied the repair of 
cartilage wounds after incising subcutaneously costal cartilage. In wounds 
twenty-four hours old a triangular gap was found filled with fibrin and 
blood-corpuscles. No change was found at this time in the cartilage- 
cells and cement-substance. The cells of the perichondrium increased in 
volume and changed in form. Gussenbauer was unable to verify the 
observation made by Reitz in wounds of trachea, that cartilage-cells are 
transformed into connective-tissue cells, and believes that the ammonia 
used by Reitz to provoke croupous pneumonia, by its introduction into 
the bronchial tubes through the tracheal wound, may have modified the 
result. He traces tissue proliferation almost exclusively to the peri- 
chondrium, the cells of which were found in all stages of division and 
development, while only a few of the cartilage-cells presented evidences 
of segmentation. Dorner studied not only the manner of repair of 
simple incised wounds of cartilage, but also produced more complicated 
injuries, and invariably found that the perichondrium took a more active 
part in the process of healing than the cartilage-cells. Wounds of fibro- 
and reticulated cartilage heal in the same manner as wounds of hyaline 
cartilage. The histological changes observed by Redfern, Dorner, and 
Gussenbauer during the repair of wounds of cartilage are descriptive of 
the changes which attend chondritis. 

VASCULAR TISSUE. 

The healing of wounds of vascular tissue is accomplished more 
rapidly than of non-vascular tissue, as the primary wound-secretion, 
which is derived mostly from the wounded vessels, forms a temporary 
cement-substance which glues the parts together, — a condition which 
renders material assistance in maintaining coaptation, — while the direct 
blood-supply to the injured part cannot fail in increasing the vegetative 



VASCULAR TISSUE. 35 

capacity of the cells, and, lastly, the leucocytes present in the recent 
wound serve as food for the cells which are undergoing karyokinetic 
changes. As a rule, to which there are few exceptions, it may be stated 
that the rapidity with which the healing process is completed is propor- 
tionate to the vascularity of the wounded part. For instance, wounds 
of the fingers heal much more rapidly than wounds of the arm or fore- 
arm, and wounds of the face more rapidly than wounds of the neck. 
Karyomitotic changes are first noticed in the nuclei of cells in close 
proximity to blood-vessels. In studying the healing of wounds of 
vascular tissue, Graser noticed that the connective-tissue cells a little 
distance from the surface of the wound were first to show evidences of 
ka^okinetic changes ; hence, it is apparent that the reparative process 
is initiated in cells most favorably located in reference to an abundant 
blood-supply, which corresponds to the location of capillary vessels 
which are undergoing dilatation prior to the formation of new blood- 
vessels. Regeneration of tissue takes place most rapidly in parts where 
new blood-vessels are developed early, rapidly, and abundantly. The 
healing process is retarded or completely suspended when the capillary 
vessels, new and old, are seriously altered by inflammation. 

Surface Epithelia. — Epithelial cells in a normal condition receive no 
direct blood-supply, but their relations to the subjacent vascular tissue 
are so intimate, and their proliferation in the healing of surface wounds 
and in the repair of defects caused by pathological conditions is so 
largely dependent on the development of new blood-vessels, that the 
study of their regeneration among the vascular tissues appears appro- 
priate. In the consideration of this subject of epidermization, it has 
been shown that epithelial cells are derived exclusively from an epithelial 
matrix, either from the margin of the wound or an islet of the epiblast 
buried among the granulations. Regeneration of epithelial cells of the 
hypoblast takes place in a similar manner as has been described in 
epidermization of a wound of the cutaneous surface. Of special interest 
is the rapid regeneration of the gastro-intestinal mucous membrane. 
A recent gastric or intestinal ulcer presents elevated and swollen 
margins, and as long as this condition remains the healing process fails 
to become established until the swelling subsides, and paving of the 
granulations with epithelial cells is postponed until the surface of the 
ulcer is nearly on the same level with the surrounding border of the 
mucous membrane. Griffini and Yassale made gastric fistulae in dogs 
for the purpose of studying directly, and during the life of the animals, 
the process of repair of wounds of the mucous membrane of the stomach. 
Through the fistula they made superficial wounds of the inner surface 
of the organ, and from their observations they satisfied themselves that 



36 PRINCIPLES OF SURGERY. 

healing takes place rapidly, and that regeneration of epithelial cells 
occurs in the peptic glands, where even as early as the third day the 
epithelial cells showed evidences of active proliferation. The new 
epithelial cells spread over the interglandular spaces, while a part of the 
glandular structure is lost during the process of healing. In traumatic 
defects where the glands have been excised with the mucous membrane 
the epithelial covering of the granulating surface is derived from the 
preformed epithelial cells of the mucous membrane bordering the wound. 
At a later stage new glands are formed by karyomitotic cellular changes 
after the normal type of development of glands in the embiyo. Even 
the youngest glands have an outlet, and the structure increases in depth 
by extension of mitotic changes in that direction. Pepsin-secreting cells 
are found only after the glands have attained nearly their normal depth. 
In one instance they were found only partly developed on the fortieth 
day. Connective-tissue proliferation takes no essential part in the 
growth and development of the new glands. Visceral wounds of the 
stomach heal kindly and rapidly. Even gunshot wounds of this organ, 
when made with a small bullet, ma}^ heal without surgical interference, 
more especially if at the time the injury has been inflicted the stomach 
is empty and all food is withheld for a few days. A strict diet is 
important in the treatment of wounds or ulcers of the stomach, as Leube 
has obtained excellent results from treatment of chronic ulcers of this 
organ b} T an exclusive milk diet. Griffini also made the observation that 
the traumatic defects which he produced in the interior of the stomach 
of dogs healed most rapidly when food was withheld entirety for a few 
days, and later on nothing but milk was allowed. From these observa- 
tions and experiments it is evident that the young cells are unfavorably 
affected Iry the action of the gastric juice. 

Quincke has demonstrated experimentally, which has been a long- 
known and familiar clinical fact, that anaemia retards regeneration of the 
gastro-intestinal mucous membrane. In two dogs a gastric fistula was 
made, and through it a defect of the mucous lining was made of the same 
size in both animals. One of the animals was in perfect health, and 
healing was completed in eighteen days. The other dog was anaemic, 
and the healing process was prolonged thirty-one days. In the healing 
of an ulcer of the stomach or any portion of the intestinal canal the 
epithelial cells are first to take an active part in establishing a process 
of repair, the connective-tissue cells entering later upon their part of 
tissue production. The healing process terminates most satisfactorily 
when only a small amount of connective tissue is formed and the 
epithelial covering is completed in a short time, as such a scar represents 
almost to perfection the normal tissue it has replaced. If a large 



TRANSPLANTATION OF SKIN. 37 

quantity of granulation tissue is produced by the connective tissue, and 
the formation of the epithelial covering is delayed for a long time, or is 
imperfectly accomplished, there is great danger of subsequent cicatricial 
contraction of the new tissue producing a stricture. The best possible 
prophylactic means against the occurrence of strictures under such 
circumstances are such dietetic and therapeutic measures as will secure 
for the ulcerated or wounded surface such favorable conditions as will 
expedite the paving of the surface with epithelial cells and limit the 
production of cicatricial tissue. 



TRANSPLANTATION OF SKIN. 

Epidermization of a large granulation surface is a slow process, 
even under the most favorable circumstances, and the resulting cicatrix 
is often large, gives rise to contractions, and not infrequently becomes 
the seat of keloid or ulcerative processes subsequently. Modern surgery 
offers means by which this tedious process can be materially shortened, 
and healing is accomplished by the formation of a more satisfactory scar. 

Reverdin's Method. — In 1870 Reverdin discovered that small, thin 
pieces of superficial skin, transplanted upon a healthy, granulating sur- 
face, formed, in a short time, organic connections with the granulations, 
and that epidermization proceeded independently from such transplanted 
islets of skin. Later, Schweninger demonstrated, by his experiments, 
that hairs could similarly be transferred to a granulating surface. An 
open, granulating wound or ulcer can be covered over with epidermis in 
a short time by resorting to Reverdin's method of transplantation of skin. 
The most essential condition for success is an aseptic condition of the 
granulations. In suppurating wounds this method of treatment is not 
applicable until suppuration has ceased and the granulations are small 
and firm. The part from which the skin is to be taken, in preference the 
thigh or arm, should be shaved and disinfected. The onl} T instruments 
required for cutting and transferring the skin is an ordinary sewing-needle 
fixed in a needle-holder, or, what is still better, a pair of haemostatic 
forceps and a sharp razor. With the needle the skin is transfixed, and 
with a razor a thin section the size of the circumference of a split pea is 
removed and at once transferred to the granulating surface with the needle 
in such a manner that the cut surface is brought accurate^- in contact 
with the granulations. As the detached portion of skin alwaj T s curls to- 
ward the raw surface at its margins, it must be carefull}' flattened out with 
the point of one or two needles, care being taken to imbed it well among 
the granulations without causing any bleeding. The grafts are planted 
in rows, commencing near the border and leaving small spaces between 



38 PRINCIPLES OF SURGERY. 

the separate grafts. Each row of grafts is then separately protected 
with a narrow strip of protective silk, and a thick, antiseptic compress 
is applied and retained by a bandage, which should exercise uniform 
gentle compression. The dressing should not be removed in less than a 
week. At this time the grafts will not only have become firmly attached 
to the subjacent surface, but each of them has become surrounded with 
a zone of new epithelial cells. As each graft now constitutes an inde- 
pendent centre of epithelial proliferation, the remaining portion of the 
granulation surface soon becomes paved by new epithelial cells, and 
epidermization and cicatrization are rapidly completed. The results 
obtained by this method of treatment have not alwa}^s been such as to 
satisfy the earlier expectations. The new skin is but a poor substitute 
for the normal structure. Epidermization is hastened, and the results 
are better than after-healing without skin-grafting, but the ideal result, 
the formation of tissue resembling true skin, is not obtainable by this 
method of skin transplantation. 

Thiersch's Method. — If after an operation or injury it is found that 
a too extensive defect of the skin renders approximation by suturing 
impossible, the surgeon has it now in his power to supply the defect at 
once by taking large skin-grafts from another part of the body, or from 
another person, and planting them in the form of a mosaic upon the raw 
surface. This method of skin-grafting in the treatment of extensive 
superficial wounds, as after the extirpation of a lupus, or a surface epi- 
thelioma, was devised by Thiersch. Experience has shown that grafts 
of the whole thickness of the skin, and an inch square, if planted smoothly 
upon the raw surface and kept uninterrupted!} 7 in contact with the wound 
by an appropriate dressing, not only retain their vitality, but enter rapidly 
into organic connections with the part with which they have been brought 
into contact, and, at the same time, their anatomical and physiological 
properties are maintained to perfection. Thiersch found that after 
eighteen hours they were supplied with new blood-vessels, which could 
be successfully injected from the vessels of the part to which they had 
become adherent. This method of transplantation of skin is now exten- 
sive^ practiced in connection with plastic operations about the face. 
For such purposes the skin is taken from the region of the trochanters, 
as the skin here is almost or entirely devoid of hair. All bleeding from 
the wound to be covered with the grafts is carefully arrested by surface 
pressure before the grafts are planted, as it is necessaiy to secure 
accurate coaptation of the wound-surfaces in order to secure a favorable 
result. The modern method of performing rhinoplasty furnishes a good 
illustration of this method of skin transplantation. 



TRANSPLANTATION OF SKIN. 



39 



As a matter of course, success by this method of skin transplanta- 
tion can only be expected when the wound and grafts are aseptic, and 
the parts are kept in this condition at least until vascularization of the 
grafts has taken place. After the grafts have been planted the treat- 
ment of the wound is the same as in Reverdin's method. During the 
after-treatment it is important to secure rest for the part, and to prevent, 
by appropriate means of fixation, even the slightest displacement of the 
grafts in any direction. A good plan is to apply a thin plaster-of-Paris 




Fig. 20.— Rhinoplasty and Transplantation of Large Skin-grafts. (Thiersch.) 

A, A, skin-flaps from face turned inward and covered with large flap from forehead, C after C', and B 
after B'. Defects covered with mosaic of large skin-grafts from trochanteric region. 

bandage over the dressing. Schede has substituted Thiersch's for Re- 
verdin's method in the treatment of granulating surfaces by skin-graft- 
ing, and the results have been very gratifying. The granulating surface 
is transformed into a recent aseptic wound by removing the granulations 
with a sharp spoon. After all bleeding has ceased the wound is covered 
with large skin-grafts in the manner described. The skin obtained after 
this method of transplantation presents a normal appearance. I have 
repeatedly seen that, after excision of an epithelioma of the frontal or 
parietal region, a defect the size of the palm of the hand was healed 



40 PRINCIPLES OF SURGERY. 

completely in less than three weeks by using Thiersch's grafts. This 
method of skin-grafting must be a welcome resource to the oculists in the 
operative removal of tuberculous lesions and malignant affections of the 
eyelids, as well as in the treatment of some forms of ectropion. 

Wolfe's Method. — Wolfe has obtained excellent results by covering 
defects of skin an inch or more in diameter with a single graft of skin 
deprived of every vestige of subcutaneous fat. The removal of the 
graft must be done with the utmost care, to insure the entire thickness 
of the skin, and equal care is necessary not to transfer adipose tissue. 
If necessary, the graft may be fastened in place with a few fine catgut or 
horse-hair sutures. 

Hirschberg's Method. — Hirschberg has been successful in planting 
large skin-grafts without depriving them of the subcutaneous fat. In 
my own hands Wolfe's method has yielded better results. 

Transplantation of Mucous Membrane. — In the treatment of traumatic 
or ulcerative defects of accessible mucous membranes, it would seem 
that restoration of the defect by transplantation of grafts of mucous 
membrane, if found feasible, would be the ideal treatment. The first 
attempt at transplantation of mucous membrane was conducted by 
Czerny, in 1811. From 1873 to 1888 it found practical application, but 
exclusively in ophthalmic surgery. Wolfler has recently shown that 
such a method of treatment is not only practicable, but has resorted to 
it successfully in the treatment of obstinate strictures of the urethra. 
After excision of the cicatrix at the seat of resection he sutured a cir- 
cular graft of mucous membrane to each end of the resected urethra, 
and had the satisfaction to observe that the graft not only retained its 
vitality, but became adherent and constituted an essential part of the 
new portion of the urethra. Wolfe has also succeeded in transplanting 
the whole of the tissues of the conjunctiva of the rabbit on to that 
of man, in order to fill a defect caused by cicatricial contraction. 
Djatschenko, in 1890, studied this subject experimentally, and eluci- 
dated the histological process. He experimented on dogs, taking 
mucous membrane from the mouth and inserting it in defects made 
by excising, portions of the conjunctiva. He found complete union 
toward the ninth day, no real cicatricial tissue forming. He places 
great stress on rendering the graft bloodless and washing it in a warm 
6-per-cent. solution of salt before it is implanted. While the graft 
should be freed of all fat-tissue, care should be taken not to deprive 
it of its submucous cellular tissue, as otherwise the conditions for the 
re-establishment of the circulation in the transplanted piece are less 
favorable. Another important rule laid down is to cut the graft suf- 
ficiently large to cover the entire defect, as the uncovered portion forms 



BLOOD-VESSELS. 41 

a scar. This method of dealing with large defects of mucous surfaces 
accessible to direct treatment holds out many inducements for future 
imitation. The difficulties in the way of equal uniform success in the 
transplantation of grafts of mucous membrane, as in skin transplantation, 
are owing to the location of the seat of operation. In the former instance 
it must always be such as to preclude the possibility of securing perfect 
asepsis, on the one hand, and the impossibility of applying an efficient 
protective dressing ; at the same time, it is also more difficult to obtain 
the proper material for the grafting. 

CONNECTIVE TISSUE. 

The granulations seen upon a wound or ulcerating surface are 
formed almost exclusively by the transformation of mature connective 
tissue into embryonal tissue, the cellular elements of which they are 
composed being embryonal connective-tissue cells. This transition of 
mature into embr} r onal cells is accomplished by karyokinesis. As con- 
nective tissue is found almost in every part and organ of the body, it 
takes an active part in the repair of all wounds, and, when the more im- 
portant tissues in the wound cannot be approximated for organic union 
to take place, its greater vegetative capacity enables it to produce a large 
amount of new material, which later forms a connecting bridge of cica- 
tricial tissue. For instance, in a transverse wound of a muscle, where it 
is often difficult, if not impossible, to keep the divided ends sufficiently 
approximated for the wound to heal by the interposition of new muscle- 
cells, the gap is spanned by a band of connective tissue, which, if not 
completely, at least partially, restores the function of the muscle 03' fur- 
nishing it with two additional fixed points of attachment. Graser has 
shown that the first karyokinetic changes are seen in connective-tissue 
cells some distance from the surface of the wound, and that the new cells 
reach the surface with the new blood-vessels, where they constitute the 
granulation tissue. In aseptic wounds, where cicatrization progresses 
rapidly, the embryonal connective-tissue cells, or granulation cells, are 
short-lived, as they are rapidly transformed into mature connective tissue, 
which here constitutes the cicatrix. In suppurating wounds the super- 
ficial layer of embryonal cells is brought in contact with the pus- 
microbes and their ptomaines, which destroy the protoplasm of the cells, 
when they are transformed into pus-corpuscles ; while those nearer the 
blood-vessels retain their vitality and capacity of undergoing cicatrization. 

BLOOD-VESSELS. 

Wounds of large blood-vessels, with few exceptions, require such 
measures in their treatment which completely arrest the circulation and 



42 



PRINCIPLES OF 'SURGERY. 



which aim at permanent obliteration of the lumen by the usual method 
of cell proliferation and cicatrization. A wound of an artery, if accessi- 
ble to direct treatment, should be treated by cutting the vessel completely 
across and applying a ligature to each end. A small wound of a large 
vein can be treated successfully, under favorable conditions, by closing 
it with a lateral ligature. With a tenaculum the margins of the wound 
are transfixed, and, by making slight traction, the vein-wall is raised, 
and around the base of the little cone thus formed a fine catgut ligature 
is applied. If the wound remains aseptic, the mural thrombosis at the 



Vasa vasorum. 



Intima. 



Partly-formed connective 
tissue from endothelia. 




Proliferated 
connective 
tissue in 
lumen. 



/ 

"Endothelial (£_ j 

proliferation. — — . 



Fig. 21.— Microscopical, Appearances op the Interior of Artery of 
Dog Forty-nine Days after Ligation. Transverse Section 
through Border of Artery. X 240. 

seat of ligation is slight, and the closure of the wound is effected 
without obliteration of the lumen of the vessel. Larger vein wounds 
have been successfully treated b}^ suturing with fine catgut. The 
sutures are inserted in the same manner as Lembert's suture in closing 
a wound of the intestine. A wound of a blood-vessel usually termi- 
nates, spontaneously or through the intervention of art, in permanent 
interruption of the circulation by the formation of an intra-vascular 
cicatrix. For many years it has been maintained that obliteration of 
a vessel after injury, disease, or ligature resulted from what was termed 
"organization of the thrombus." It was believed that the thrombus 



BLOOD-VESSELS. 



43 



became vascular either from the lumen of the vessel or the vasa va- 
sorum, and that the histological elements in the thrombus took an active 
part in the production of the intra-vascular cicatrix. Numerous experi- 
mental investigations by different authors, undertaken for the purpose of 
demonstrating that in wounds of blood-vessels healing takes place in the 
same manner as in the wounds of other tissues, have shown that the blood- 
clot always occupies only a passive role, and, if present, is only in the way 
of a speedy, definitive closure, which invariably is effected by prolifera- 
tion from the fixed cells of the vessel-wall. Eliminating the thrombus 



Young 
connective- 
tissue 
cells. 



Endothelial 
proliferation. 




Proliferation 
of connective 
tissue. 



Connective 
tissue of 
vein- wall. 



Fig. 22.— Microscopical Appearances of the Interior of Vein of Dog 
Forty-nine Days after Ligation. Transverse Section of Part of 
Vein in Ligated Portion, x 240. 



as an active agent in the obliterating process, we can say that union be- 
tween the tissues which are brought in contact by the ligature takes 
place by tissue proliferation from the walls of the vessel itself. In the 
true sense of the word, direct or immediate union is as impossible here 
as in any other wound, and, like everywhere else, the intra-vascular cica- 
trix is formed from tissue derived from the tissue of the injured vessel- 
wall. In case the inner tunics are severed by the ligature, the lacerated 
surfaces are brought in contact with the adventitia, and repair takes 
place as in other tissues which are largely composed of connective tissue, 
the process extending from both sides of the ligature, where endothelia 



44 PRINCIPLES OF SURGERY. 

assist in the process of cicatrization. If, on the other hand, the con- 
tinuity of the vessel is not destroyed by the ligature, and the intima is 
simply brought in contact without being ruptured, the new cells from the 
connective tissue perforate the endothelial lining, and the new elements 
of the latter join in the reparative process by being converted from their 
embryonal state into connective tissue. The histological changes in the 
interior of veins undergoing obliteration are the same as in arteries, the 
new material of which the cicatrix is composed being derived exclusively 
from the endothelial and connective-tissue cells. 

J. Collins Warren, who has done excellent work in studying experi- 
mentally the healing of arteries after ligature, maintains that he has seen 
sufficient evidence in his specimens that the muscle-cells in the tunica 
media take an active part in the process of repair. ' The same author 
compares the process of healing in arteries to the formation of callus after 
fracture, and hence calls the intra-vascular material the internal and the 
extra-vascular the external callus. Ballance and Edmunds, in their 
classical work "Ligation in Continuity," have given the profession the 
most reliable and exhaustive treatise on this subject. Tfee numerous 
experiments of the author on ligation of arteries and veins have demon- 
strated, to his own satisfaction, that the most speedy obliteration of a 
vessel is obtained if the vessel is rendered bloodless by the application 
of two ligatures. The ligatures are applied with sufficient firmness to 
obliterate the lumen of the vessel without rupturing any of its •coats. 
After ligation the walls of the vessel became thickened ; so that, a few 
weeks after the ligatures had been applied, the vessel presented a spindle 
shape, tapering toward each side, a condition entirely due to the form- 
ation of new material, — the external callus of Warren. The bloodless 
space between the ligatures is obliterated in a short time by cells which 
enter it from the vessel-wall. 

In the obliteration of veins and ligation of arteries in their con- 
tinuity, the double ligature, including a bloodless space about \ inch in 
length, places the tissues in the most favorable conditions for speedy, 
definitive closure by an intra-vascular cicatrix. When the vessel is ex- 
posed catgut should be used, but in the subcutaneous ligation of veins 
silk is preferable. Since the introduction of antiseptic surgery and the 
aseptic ligature, secondary haemorrhage has become an exceedingly rare 
accident, and, when it does occur, it is in wounds where the antiseptic 
measures have failed. A vessel in an aseptic wound, tied with an aseptic 
ligature, becomes, in a few hours, the seat of a regenerative process which 
effectually guards against the possibility of hemorrhage, even if the 
mechanical obstruction caused by the ligature should be removed after a 
few days. The aseptic ligature, applied under strict antiseptic precau- 



BLOOD-VESSELS. 



45 



tions, has been advantageous in other directions. The older surgeons 
alwa} f s expected, after ligating an artery in its continuity, that the 
thrombus would extend on the proximal side to the nearest collateral 
branch, and, on this account, they were always anxious to secure a space 
of an inch or more between the ligature and the nearest large collateral 
branch, in order to prevent secondary haemorrhage. The aseptic ligature 
is never followed by such extensive thrombosis, and the intra-vascular 
cicatrix is often exceedingly narrow, — in fact, almost linear. The limited 
thrombosis and the prompt formation of an intra-vascular cicatrix place 
the surgeon now in a position that he can ligate a large artery, close to a 
collateral branch or near a point of bifurcation, without a particle of fear 
of incurring secondary haemorrhage. In the ligation of veins the aseptic 
ligature has dispersed all fear of suppurative thrombo-phlebitis and 
pyaemia, — complications which were formerly so much feared, even after 
insignificant operations on veins. In the repair of wounds union between 
the divided ends of blood-vessels is probably never effected. The vessel- 




Fig. 23.— Femoral Artery of Dog Fifty Days after Double Ligation 
with Silk. BEiiOW, Transverse Section showing Bloodless Space 
Filled with Cicatricial Material. (Natural Size.) 

ends are temporarily closed either by tying with a ligature or by the 
formation of a thrombus, the former being the case when vessels of some 
size have been divided, the latter being accomplished usually spontane- 
ously in vessels which give rise to parenchymatous haemorrhage. In 
either instance the ends of the vessel are, later, permanently sealed by the 
formation of a cicatrix by proliferation of fixed tissue-cells, the endo- 
thelia, and connective-tissue cells. The interrupted circulation between 
the two sides of the wound is restored indirectly through collateral 
branches, which are always new blood-vessels. The angioblasts in the 
injured capillary vessels assume active tissue proliferation within twenty- 
four hours after the injury has occurred, and through them, almost exclu- 
sively, the new blood-vessels are formed, in the shape of loops, which, 
coming, as they do, from both sides, establish the vascular connection 
between the two surfaces of the wound. (See Fig. 24.) Many of these new 
blood-vessels disappear after the consummation of the reparative process, 
while others remain as permanent collateral vessels between the closed 
ends of the old blood-vessels permanently separated by the injury. 



46 



PRINCIPLES OF SURGERY. 



MUSCLES. 

It is only quite recently that it has been ascertained that a divided 
muscle can unite, under favorable circumstances, by interposition of new 
muscular tissue between the divided ends. It was formerly believed 
that healing was always accomplished by the formation of connective 
tissue, and that the ends of the cut muscle remained permanently sepa- 
rated by a bridge of cicatricial tissue. The theory that connective tissue 
can be transformed into muscular tissue is untenable, since Pflueger has 
demonstrated the minute structure of muscular fibre. Kolliker has 
shown that the fibrillae in the mus- 
cle-fibre constitute the real ground- 
substance. Rabl ascertained, by his 
embryological researches, that the 
muscular tissue is derived from a dis- 
tinct portion of the mesoblast, and, 
consequently, proved that, at a very 
early period of embryonal life, an 
absolute difference takes place be- 
tween muscular and connective tis- 
sue. Heterotopic muscular struct- 
ures must, therefore, be looked upon 
not as products of connective-tissue 
proliferation, but as a growth from 
a displaced embryonal matrix of 
muscular tissue. 

The vegetative capacity of mus- 
cle-cells, striped and unstriped, is 
quite limited, as compared with some 
of the other tissues ; so that, if the 
ends of a muscle that has been cut 
transversely are separated for more 
than an inch, complete restoration of 
the continuity of the muscle is not 

attained, and the two ends are connected by a band of connective tissue. 
If, during the healing of the wound, the cut surfaces of the muscle are 
kept in accurate contact, and even if a gap of half an inch exist between 
them, restoration ad integrum takes place by proliferation of the muscle- 
elements near the seat of injury. 

Non-striated Muscular Fibre. — Stilling and Pfitzner, as well as 
Busachi, have shown that unstriped muscular fibres multiply by indirect 
division of their nuclei, and, in the repair of wounds of this tissue, new 
fibres are produced exclusively by this method. These authors studied 




Fig. 24. — Collateral Circulation 
Eight Months after Ligation 
of the Aorta in a Dog. (Luigi 
Porta.) 



MUSCLES. 47 

the karyokinetic changes in the muscular fibres of the triton taeniatus. 
They observed, after the division of the nucleus in the usual manner by 
karyokinesis, that as the new nuclei separated and approached the poles 
of the cell the protoplasm of the cell-body at the transverse axis became 
narrower, showing a well-marked constriction, which would indicate that 
subsequently cell-division occurred. Herczel witnessed similar changes 
in the hypertrophic muscular coat of the intestines on the proximal side 
of strictures. In defects caused by the injury, removal, or destruction 
of unstriped muscular fibres, regeneration takes place only from the 
margins, while the centre at first is occupied by connective tissue. The 
new muscular fibres are at first irregularly arranged, and it is only 
toward the completion of the healing process that the new tissue repre- 
sents to perfection the mature muscular fibres. Klebs is of the opinion 
that the leucocytes serve as food for the cells which undergo kaiyokinetic 
changes. 

Striated Muscular Fibre. — 0. Weber, as early as 1854, claimed that 
in the healing of wounds new muscular fibres are produced, but, in accord- 
ance with the views which then prevailed, believed they were derived 
from connective tissue. Wittich saw, in hibernating frogs, new fibres 
which he believed had developed from the cells of the internal peri- 
mysium. In 1865, after an examination of a genuine myoma strio- 
cellulare, Buhl expressed the opinion that new muscular fibres are 
produced from old fibres. In the same year Waldeyer discovered the 
muscle-cell sheath, and he regarded the cell inclosed by it as a derivative 
of the nucleus of the fibre, but, with Zenker and others, he still regarded 
the perimysium as the source of new muscular fibres. In 1868 E. 
Neumann made the observation that after section or laceration of a 
muscle the ends of the fibres became the seat of active tissue changes, 
which resulted in the formation of what he termed muscle-buds. These 
muscle-buds were not only found at the ends of the fibres, but also on 
their sides ; at first they were seen to be composed of numerous nuclei 
and protoplasm, while later they were transformed into striated fibres. 
The sarcolemma is such a delicate structure that new cells which form 
within it readily find their way through it, and appear upon its outer 
surface in the shape of buds, as described by Neumann. 

Tizzoni has recently investigated the karyokinetic changes in the 
nuclei or sarcoblasts in the perinrysium during the repair of muscle 
wounds. The first evidences of cell proliferation were seen in the nuclei 
or myoblasts nearest the seat of injury, and proliferation took place in 
fibres which had undergone degeneration as well as in those which pre- 
sented a striated appearance. Leven found, during the first twenty -four 
hours after injury, an increase of nuclei of the sarcolemma sheath. These 



48 



PRINCIPLES OF SURGERY. 



new nuclei are arranged in the form of rows and heaps, and by mutual 
pressure are flattened. Many of these new elements present karyokinetic 
figures, and around them protoplasm is deposited, and the new cells 
become spindle-shaped. The new cells increase in number from the third 
to the fourth day, so that at this time from five to six can be seen under 
one field. Klebs studied regeneration of muscle in young guinea-pigs 
after puncturing subcutaneously the gastrocnemius muscle. He came to 
the following conclusions : A portion of the muscular fibres die and 
shrink, and in this condition they can be stained more deeply with 
hematoxylin than the others. Such fibres are completely removed by 
absorption within the first four da} T s. In the fibres which remain striated 




Fig. 25.— Muscular Fibres Near a Wound in a State of Proliferation. 

(O. Weber). 

A. contused end of muscular fibre ; B, muscular fibre retracted within sarcolemma, the latter 
terminating in a sharp point ; C, old fibre degenerated into a colloid mass ; D, young nuclei between 
and upon fibres ; E, nuclei surrounded by cell-protoplasm ; F, new cell, showing scriations ; G, new 
muscular fibre. 



the fibrillar become plainer, and in them the regenerative process can be 
distinctly seen. The nuclei increase in number, and are packed densely 
together, but at this stage he was unable to detect any evidences of 
kar} T okinesis. During this stage Steudel was also unable to detect any 
appearances which indicated indirect cell division. These young cells are 
called sarcoblasts b} T Klebs, and their transformation into muscle-fibres 
is effected b} T aggregation around them of a very thin layer of proto- 
plasm. The youngest cells are round, and the change into spindle form 
is gradual. The new cells are arranged in rows between the old muscular 
fibre (Fig. 25, between G and B). Some authors believe that the sarco- 
blasts unite end to end, and that the muscular fibre is formed in this 



MUSCLES. 



49 



manner. Kraske and Klebs maintained that muscular fibres result from 
a single cell by gradual elongation of the cell-body. In the regeneration 
of the muscular fibres of the heart after injury, Martinti and Bonome 
witnessed karyomitotic changes in the interior of the sheath of numerous 
fibres, while in others where degenerative changes had taken place no 
such changes could be seen. In wounds of the heart of old rats karyo- 
mitosis commences five to six days after the injury, and does not last 
longer than six to seven days, and results only in incomplete regener- 
ation. In myocarditis the formation of new muscular fibres has been 
observed by Yirchow, Boettcher, and Waldeyer. 

Muscle Suture. — In the treatment of recent wounds special pains 
should be taken to secure accurate approximation between the ends of 
divided muscles. For this purpose special means must be employed 




Fig. 26.— Muscle Suture. 



when large muscles have been divided transversely. In such cases the 
retraction which follows gives rise to great separation, which can only 
be overcome by suturing respective ends separately with buried animal 
sutures. Great care is necessary not to invert the margins, but to unite 
the cut surfaces throughout, using for this purpose, if necessary, as many 
as six sutures, which must include considerable tissue in order to prevent 
their tearing through. The muscle ends should be secured with a mat- 
tress suture of chromicized catgut as shown in Fig. 26, and the edges care- 
fully coaptated with three or more points of suture of the same material. 
In muscles supplied with a well-marked sheath this should be sutured 
separately. In the after-treatment it is necessary to place the limb in 
such a position that will relax the sutured muscles, and to secure immo- 
bility of the limb in this position by a proper mechanical support, which 



50 



PRINCIPLES OF SURGERY. 



should not be removed until the healing process is completed, in order 
to prevent subsequent diastasis between the sutured ends. When it is 
desirable to elongate a contracted muscle in the correction of deformities, 
as in the treatment of torticollis, the contracted muscle should be exposed 



d 







Fig. 27.— Tenorrhaphy. (Esmarch.) 

a, mattress suture ; b, c, after Wolfler ; d, e, paratendinous suture, after Hueter. 

by incision, and after section a suture a distance is applied. A number 
of heavy catgut sutures will answer an excellent purpose, as they will 
maintain fixation of the separated ends in a desirable position, and will 
furnish an admirable scaffolding for the new connective-tissue cells, which? 






Fig. 28.— Tendoplasty. {Esmarch. ) 
a, after Madelung ; b, after Tillaux ; c, after Hueter ; d, after Gluck. 

later on, are transformed into a tendon which permanently connects the 
retracted ends of the divided muscle. 

Tenorrhaphy. — The operation of suturing a tendon is called tenor- 
rhaphy. The histological processes in the regeneration of a tendon are 



MUSCLES. 



51 



the same as in the repair of connective tissue. Tendons are composed 
of compact connective tissue surrounded by a delicate membrane, — , 
the tendon-sheath. In injuries of tendons the fibroblasts furnish the 
new material, which is interposed between the cut or torn ends and 
which restores the continuity of the tendon. The process of repair is 
instituted near the tendon-ends and shows itself in the splitting up of 
the fibrils. The new material acts first the part of a cement-substance, 
but in the course of two or three weeks is transformed into new con- 
nective tissue. In open wounds, 
complicated by injury to tendons, 
the careful surgeon never neglects 
to place the tendon-ends in the 
most favorable conditions for 
speedy and satisfactory repair 
by resorting to primary tendon 
suture. If a number of tendons 
have been injured at the same 
time, it is often difficult to iden- 
tify the ends which belong to- 
gether and much time is often 
consumed, and a great deal of 
care must be exercised in finding 
and suturing the respective ends. 
If the proximal end has retracted 
into the sheath beyond easy reach 
it is better to lay the sheath open 
than to make repeated fruitless 
attempts to grasp the tendon. 
The best suturing material is 
chromicized catgut. The tech- 
nique of tenorrhaphy is well 
shown in Fig. 27. 

The surgeon is often called 
upon to restore the continuity of a 

tendon in cases in which primary tendon suture was neglected or in 
which it failed, and then resorts to secondary tenorrhaph} 7 , which is 
performed in the same manner as primary tendon suture, after the 
tendon-ends have been exposed and vivified. 

Tendoplasty. — In cases in which the loss of substance in tendon 
injuries renders approximation of the tendon-ends impossible, and in 
many cases of open tenotomies for contractured tendons, restoration 
of the continuity of the tendon can only be secured by a plastic oper- 




Fig. 29.— Secondary Suturing of Exten- 
sor Tendons of Fingers by the 
suture a distance. 



52 



PRINCIPLES OF SURGERY. 



ation, which in this instance is called tendoplasty. A number of valuable 

procedures are shown in Fig. 28. 

Gluck interposes between the ends of the tendon a braided bundle 

of catgut, which acts as a temporary bridge-work for the fibroblasts and 

which is replaced, in the course of time, by 
permanent tissue. E. J. Senn employed this 
method of suturing a distance with great 
success in a case of extensive loss of tendon- 
tissue involving all of the extensor tendons 
of the lingers of one hand. The degree of 
separation of the tendon-ends and technique 
of operation are shown in Fig. 29. The 
patient recovered full use of the extensor 
tendons in the course of two months. 

An exceedingly valuable method of 
effecting elongation of a contractured tendon 
was devised by Anderson. It consists in 
splitting the tendon longitudinally and cut- 
ting each half on opposite sides sufficiently 
far apart so that the necessary degree of 
elongation can be secured by suturing to- 
gether, end to end or laterally, the long ends. 
(Fig. 30.) In uniting a large tendon, either by 
simple suturing or by a plastic operation, it 
is important to suture the sheath separately ; 
or, if this is absent, to make a new sheath of 
connective tissue with which the tendon 
should be covered. Immobilization of the 
limb must be continued until the process of 
repair is completed, which will require from 
three to six weeks. 



BONE. 

The granulation material by which the 
fractured bone unites is called callus. 
According to the location of this material 
around, within, or between the fragments, we 
speak of an external, internal, or intermediate 
callus. The external or provisional callus is abundant, as a rule, where 
the broken bone is surrounded by a thick cushion of soft parts, and when 
the fragments are not well immobilized. It forms early and disappears 
gradually after the fracture has united. The internal or medullary callus, 



.!pi!|!|pffi| 

Fig. 30.— Tendon Elonga- 
tions. 



BONE. 53 

which takes the place of the medullary tissue in fractures of the shaft of 
the long bones, serves a useful purpose as a means of fixation of the 
fragments, and is also removed in the course of time after union has 
taken place, and with its disappearance the medullary cavity is restored. 
The intermediate or definitive callus is the material interposed between 
the broken surfaces, and which is transformed into permanent tissue. 
Callus is the product of cell proliferation of those tissue-elements which 
are directly concerned in the growth and development of bone. 

Duhamel de Monceau attributed to the periosteum and endosteum 
the function of producing callus. Haller and his prosector, Detlef, be- 
lieved that the periosteum takes no part in the regeneration of bone, but 
that callus is derived from the fractured ends of the bone, more especially 
the myeloid tissue. Dupuytren maintained that the periosteum and the 
paraperiosteal connective tissue were bone-producing tissues. Cruveil- 
hier claimed that the lacerated soft tissues around the fractured bone- 
ends, the periosteum, connective tissue, muscles, tendons, etc., furnished 
the material for the callus. 

Flourens claimed that the periosteum alone could produce new bone. 
Rokitansky asserted that callus is developed directly from bone and its 
connective tissue, including the periosteum. From his own experimental 
work, R. Heine came to the conclusion that regeneration of bone takes 
place from connective tissue in and around bone and the periosteum. 
According to Virchow, callus is produced from connective tissue outside 
of the bone, as well as from the medullary tissue. Hofmokl con- 
sidered as sources of callus formation the periosteum, bone, and mar- 
row. Gegenbauer takes the ground that bone is produced directly from 
connective tissue. He asserts that Sharpey's fibres, if traced carefully, 
Can be seen springing from a bony point between the Haversian canals, 
from which point they radiate toward both sides into the lamellar sj^s- 
tems. The fibres form net-works, and at points of intersection bone- 
cells are produced, and a deposit of lamellae takes place around the 
connective-tissue fibres. 

It is now generally conceded that the provisional callus is the prod- 
uct of tissue proliferation from the periosteum, while the definitive or 
permanent callus is produced directly from the medullary tissue. The 
provisional callus is nature's splint, its only object being to immobilize 
the parts until the definitive callus firmly and permanently unites the 
fragments. The temporary callus is an accidental product, and appears 
earliest and most copiously where the paraperiosteal tissues are most 
abundant and motion between the fragments greatest ; the intermediate 
or permanent callus is produced later, and is transformed into permanent 
tissue. Oilier and Bncholtz, in their experiments on transplantation of 



54 



PRINCIPLES OF SURGERY. 



periosteum, found that the transplanted tissue first produced cartilage, 
which later was transformed into bone ; but they also ascertained that 
such bone disappeared again unless it formed in a place where bone nor- 
mally exists. Cohnheim and Maas came to the same conclusion from their 
experiments on intra-venous transplantation of periosteal grafts. It is 
possible that special cells (Mastzellen) are the active agents in the 
removal of tissue in places where it has no physiological existence. 




Fig. 31.— Section through Callus Fifty-two Hours after Fracture of Ulna 
from Rabbit. Beginning Formation of Osteoid Tissue. (Bajardi.) 

A, cortical portion of bone ; B, osteoid tissue ; C, beginning of formation of a lamella, surrounded by 
osteoblasts; D, periosteum. (Hartnack, Obj. 8.) 

Macewen has maintained for years that bone grows only from bone, and 
the results obtained by applying this principle in practice speaks 
strongly in favor of this supposition. That medullary tissue alone can 
produce bone has been experimentally demonstrated by Bruns. The 
osteoblasts from which bone production alone can take place are found 
in the periosteum, more especially its inner layer, the cambium, aud in 
the interior of bone. Regeneration of bone from these cells takes place 
in two ways, — either the cells are transformed into an osteoid tissue, or 



BONE. 



55 



they are first changed into cartilage-cells, and the latter at a later stage 
undergo ossification. The osteoblasts in the periosteum, and, to a lesser 
extent, those in the central medullary cavity, produce bone by this indi- 
rect method, while in other places ossification is effected in a more direct 
wa} T by the osteoblasts being transformed into an osteoid substance. 

In the normal regeneration of bone, cartilage plays an important part. 
As the bone-cells disappear, or at least lose their nuclei where cartilage- 
cells form, it is probable that the cartilage-cells represent structures in- 
termediate between osteoblasts and bone-cells. Cartilage is abundant 



P 



-reSSaMggrW"-* 




R 



%-^^ss 



< **%g3!z££F ! ^& 



?&*&<&. 




~r K 



Fig. 32.— Transverse Section through Callus of Tibia of Rabbit Forty Days 
after Fracture, with External Resorption. (Maas.) 

P, periosteum, much thickened ; R, giant cells or osteoklasts ; G, blood-vessels ; M, medullary resorption 

spaces ; K, compact portion of bone. 

where union is retarded, and especially in cases of pseudarthrosis. 
During ossification the l^aline cement-substance between the cartilage- 
cells is dissolved, and the space gives way to lamellae, while the cells are 
transformed into bone-cells. According to Krafft, multiplication of the 
bone-producing cells of the periosteum can be seen twenty to thirty 
hours after fracture, in the shape of karyokinetic figures in the nuclei of 
the cells, while somewhat later the same figures are to be seen in the 
endothelia lining the blood-vessels. The new cartilage-cells also 
multiply by karyokinesis. Like in the healing of wounds in soft parts, 
the cells on the surface of the fracture take no part in the process of 



56 PRINCIPLES OF SURGERY. 

regeneration, as their proliferation capacity lias been destroyed by the 
trauma as well as the sudden diminution of the vascular supply. Osteo- 
porosis at the seat of regeneration is always present, and results from 
the action of another kind of cells discovered by Kolliker, — the osteo- 
klasts. Robin described them as myeloplaques. They are found in 
Howship's lacunae where resorption takes place. 

The osteoklasts appear to be nothing else but myeloid cells which 
have lost their bone-producing function ; they are in reality hyperplastic 
osteoblasts. Absorption of bone takes place because these cells do not 
produce bone. There is no reason to believe that these cells are altered 
bone-cells, as no intermediate forms have been found. Ziegler does not 
assign much influence to these cells in the resorption of bone. Wegner 
has shown that in pathological processes in bone where resorption takes 
place they are arranged along the sides of blood-vessels, and on this 
account he believed they were derived from the vessel-wall. Klebs is of 
the opinion that the osteoklasts may secrete a chemical substance which 
decalcifies the bone. Resorption of superfluous callus is accomplished 
undoubtedly by the action of osteoklasts, an exceedingly useful function, 
as by it form and strength of the broken bone are restored. 

According to Meyer the architectural structure of the spongiosa, 
after the healing of a fracture, adapts itself to the new conditions, so 
that the new traction and pressure-curves are arranged in such a manner 
as will resist the greatest degree of force. This capacity of adaptation 
is present to a very high degree in bone. 

Abnormal and Defective Callus. — Callus may be formed in excess of 
local requirements after a fracture, and } T et no union take place. The 
osteoblasts respond promptly to the stimulus created by the trauma, 
karyokinetic changes occur early, new cells are formed with great 
rapidity, and a large mass of new material is deposited at the seat of 
fracture, but bony consolidation does not occur because the new tissue 
does not undergo ossification. The normal development of cells is 
arrested at an earty stage, and the chemical processes upon which ossifi- 
cation depends are delayed or fail to appear altogether. Prompt bony 
union does not only imply that the osteoblasts at the seat of fracture 
should undergo karj^okinetic changes and multiply, but that the new 
tissue must be placed under the influence of favorable chemical conditions 
which will enable it to be transformed into bone. 

A few years ago B. von Langenbeck reported 2 cases of fracture of 
the femur, where he resorted to amputation of the thigh under the belief 
that the luxuriant callus, which formed in each case at the seat of 
fracture, was a sarcoma. Microscopical examination in both instances 
showed that the swelling was composed of cells which are found in callus 



BONE. 57 

at an early stage of its formation, without any evidences of ossification 
of the new material. The causes of delayed ossification are not known, 
but, as in a number of instances of profuse callus formation and delayed 
union a vigorous antisyphilitic course of treatment produced favorable 
results, it appears that the virus of syphilis maj 7 at least be one of them. 
We know that In gummata the same conditions prevail in the persistence 
of tissue in its embryonal state for an indefinite period of time, or until 
the syphilitic virus has been removed or neutralized by proper anti- 
syphilitic treatment. 

In cases where no such cause for the delay of the transition of callus 
into bone can be surmised, the internal administration of minute doses 
of phosphorus should be tried. Kassowitz produced osteoporosis in 
animals experimentally by large doses of phosphorus, while minute 
doses produced an opposite effect. He recommended the remedy in 
small doses in the treatment of rickets, and since then it has been ex- 
tensively used in the treatment of this disease, and with the best results. 
The action of this drug undoubtedly would produce a favorable effect 
upon the osteoid material, in hastening its transition from the embryonal 
into a mature state. 

The amount of callus thrown out in every instance depends on : 1. 
The general condition of the patient. 2. The location and structure of 
the fractured bone. 3. The amount of local injury. 4. The degree of 
displacement. 5. The perfection of immobilization. 

As a rule, a minimum amount of callus is produced when the patient 
is suffering from any wasting or acute febrile affection or is the victim 
of any so-called constitutional diseases ; when the broken bone is very 
compact and located near the surface of the body ; when the injury was 
slight, with little or no displacement, and when during treatment the 
broken ends have been kept at rest and in constant and in uninterrupted 
coaptation. 

Opposite conditions are followed by an exuberant production of 
callus. The influence exercised by paraperiosteal tissues in determining 
the amount of callus is well illustrated in fractures of the tibia and ulna; 
where the bone is subcutaneous little or no callus is found, while in 
places where it is deeply covered by muscular and aponeurotic tissue the 
amount of callus is great, — in some instances so great that it fills the 
entire interosseous space, forming a bridge of bone across it, perma- 
nently cementing the fibula or radius, as the case may be, to the broken 
bone. 

To obtain bony consolidation after a fracture certain well-recognized 
conditions are necessary : 1. A sufficient blood-supply to the part. 2. 
Unimpaired innervation of the part. 3. Placing and maintaining the 



58 PRINCIPLES OF SURGERY. 

fragments in contact, or at least in such close proximity that the callus 
thrown out from both extremities can meet and establish a bony bridge 
between. Injury of any principal vessel or nerve of a limb, as a compli- 
cation of any fracture, does not only endanger the integrity of the limb, 
but may constitute an important element in the production of non-union. 

Injury of the nutrient vessels of long bones has no influence in pre- 
venting the formation of callus, claimed by several writers, inasmuch as 
the combined statistics from the practice of different surgeons do not 
sustain this assertion. An excessive supply of blood in the part — either 
from an undue afflux of blood, the consequence of an excessive irritation 
about the seat of fracture, or from obstruction to the venous return — 
frequently affects callus formation in a detrimental manner. These con- 
ditions often interfere with the normal reparative process, the histological 
elements which are intended to furnish the callus not undergoing the 
typical embryonal tissue transformation. 

The following are the principal causes which have been enumerated 
as giving rise to false joints : — 



General 



Local 



Rachitis. Syphilis. 

Scorbutus. Acute febrile affections. 

"Wasting diseases. Pregnancy. 
Prolonged lactation. 

Interposition of soft tissue between fracture. 

Separation of fragments. 

Imperfect immobilization. 

Imperfect circulation from concomitant swelling, too tight 

dressing, or position of limb. 
Obliquity of fracture. 
Complication of fracture. 

I have not enumerated old age as a cause for delayed or non-union. 
Statistics show that these accidents are found almost exclusively in 
young people at the age of 20 to 35 years. With the exception of joint 
fractures, fractures unite promptly and in a short time in the aged. 
Senile osteoporosis may be considered a favorable condition for a callus 
formation. 

A great diversity of opinion prevails among surgeons in regard to 
the influence of general conditions on the production of callus. Some 
claim that non-union is almost invariably due to general causes. I 
recollect very well the remark of the late Professor von Nussbaum on 
this subject. In a lecture he claimed that nearty all, if not all, fractures 
that fail to unite by bone occur in 'patients suffering from some con- 
stitutional taint, more especially syphilis. He referred to several cases 
where no attempt at union took place under the most favorable local 



BONE. 59 

conditions, and where a course of mercurial inunction was promptly 
followed by bony consolidation. 

Defective callus formation will necessarily follow a fracture if the 
osteoblasts fail to enter upon an active process of cell proliferation. 
These are the cases where the surgeon resorts to local measures which 
are intended to stimulate the cells to increased activity. Fractures of 
the lower extremities which have failed to unite as long as the patient is 
kept in bed often unite promptly after he is allowed to walk around on 
crutches, the favorable change being brought about by an increased 
blood-supply to the seat of fracture. 

Dumreicher suggested that the local blood-supply could be increased 
by applying a compress and bandage above and below the seat of fracture, 
while Helferich more recently, and with the same object in view, advised 
moderate constriction with an elastic bandage applied in such a manner 
as not to interfere with the arterial circulation. Rubbing of the frag- 
ments forcibly against each other is an old method of treating delayed 
union, and has often been sufficient to rouse the dormant osteoblasts 
into active cell proliferation. The distinguished Brainard made the 
treatment of delayed union a special study during many years of his 
useful life, and devised a new method of treatment, — the subcutaneous 
drilling of the ends of the fragments, — which has been extensively prac- 
ticed and has yielded most excellent results. The drilling of the ends 
of the broken bone has a most decided effect in stimulating the sluggish 
reparative process, as it produces osteoporosis and increases the vascu- 
larity of the parts, both of these conditions being well calculated to 
increase the local nutrition. Dieffenbach went one step farther, and 
advised the use of ivory nails, which were allowed to remain until they 
became loose and dropped out. The term non-union is a relative one, as 
in some fractures this condition may have been reached in three to four 
months, while others may unite after a year. 

In a fracture of the femur, in a healthy man who came under the 
author's observation, that had not united a }^ear after the accident, bony 
consolidation took place after this time without any operative inter- 
ference. In another case bony union did not occur until nearly two years 
after the fracture had taken place. When a pseudarthrosis has once 
become established, all measures which have been found useful in the 
treatment of delayed union are useless, and the only rational treatment 
in such cases consists in transforming the old fracture into a recent one. 
The ends of the fragments are exposed, the interposed ligamentous 
structures — muscles or tendons — or false joint excised, and the ends 
vivified in such a manner as to furnish large surfaces for apposition. 
The bone should never be cut transversely, but always obliquely, or, 



60 



PRINCIPLES OF SURGERY. 



what is still better, V oik ma mi's step-operation should be done wherever 
the existing conditions make this possible. Direct fixation of the frag- 
ments with aseptic bone or ivory nails should always be practiced, as by 
this expedient we are able to secure greater immobility between the 
fragments, and at the same time the perforations and the presence of the 




Fig. 33.— Old Method of Bone Suture. 




Fig. 34. — Improved Bone Suture. 
Transverse Fracture, Wire 
Suture including Entire Thick- 
ness op Both Fragments. 



foreign bodies cannot fail in imparting an additional stimulus to the 
tissues which will expedite the process of repair. 

The silver-wire suture has been used for a long time to secure fixa- 
tion of the fragments in recent fractures and in cases of non-union. 

In uniting oblique fragments Wille's method of suturing, shown 
in Figs. 35 and 36, is to be preferred. Bircher has employed cjdinders of 
ivory, which he introduced into the medullary cavity as a means of fix- 
ation. The writer has substituted, for the solid ivory, hollow perforated 
intra-osseous splints to meet the same indications. As another means of 
direct fixation, the author has devised and successfully employed bone 





Fig. 35.— Wire Drawn through the 
Perforation. 



Fig. 36.— Wire Tut in the Centre and 
Each Half Twisted Separately. 



ferrules in a number of cases. The shape, size, and application of these 
ferrules are well shown in the accompanying illustrations. 

The frequency with which non-union is met with after intra-capsular 
fracture of the neck of the femur has almost by universal consent been 
attributed to defective callus formation. It has been claimed that in 
such a fracture, occurring as it usually does in persons advanced in life, 



BONE. 



61 



callus production is always defective, and, as the upper fragment is but 
scantily supplied with blood-vessels, it was asserted that it was not in a 
condition to take an active part in the reparative process. The author 
made numerous experiments on animals, fracturing the neck of the femur 
within the limits of the capsular ligament, and as long as the fracture 
was treated in the customary way bony union was never attained. He 
then resorted to direct means of fixation by transfixing both fragments 




Fio. 37.— Sbnn's Hollow Perforated Intraosseous Splint. 

with an absorbable nail, and with this treatment succeeded in obtain- 
ing bony union in the majority of cases. Since that time he has 
treated fractures of the neck of the femur by immediate reduction 
and permanent fixation with a plaster-of-Paris splint, with pressure 
over the trochanter major in the direction of the axis of the neck of 
the femur with a compress and set-screw, the latter passing through 
a splint which is incorporated in the plaster-of-Paris dressing. With 
this treatment he has obtained bony union in a number of instances 






Fig. 38.— Circular Bone Fig. 39.— Triangular Fig. 40.— Wide Perforated 

Ferrule for Humerus Bone Ferrule for Bone Ferrule. 

or Femur Made of an Tibia Made of an Ox 

Ox Femur. Tibia. 



where all the signs and symptoms pointed to a fracture within the 
capsular ligament. 

It is a well-established clinical fact that in the aged other fractures 
unite readily, and pseudarthrosis is exceedingly uncommon, excepting 
after this fracture ; and the writer is satisfied that this undesirable result 
occurs more in consequence of improper treatment than defective callus 
production. If the fragments can be brought in accurate apposition 
soon after the accident has occurred, and coaptation can be maintained 



62 



PRINCIPLES OF SURGERY. 



uninterruptedly for three months by an appropriate dressing, bony union 
can be secured not only in exceptional, but in the majority of, cases. 
In the treatment of fractures, as in the treatment of wounds of the soft 
parts, accurate coaptation and effective fixation should be aimed at so 




Fig. 41.— Oblique Fracture of Femur 
United by Bone Ferrule. 




Fig. 42.— Transverse Fracture of 
Humerus Immobilized by a Wide 
Perforated Bone Ferrule. 



as to place the parts in the most favorable conditions to unite by the 
smallest possible amount of new material. 



GLANDS. 

Testicle. — Griffini studied regeneration of testicle-substance in frogs, 
dogs, chickens, and guinea-pigs. He excised a wedge-shaped piece under 
strict antiseptic precautions, and killed the animals in from three to 



GLANDS. 



63 



seventy-five days. Examination of the specimens showed that an in- 
crease of tubuli seminiferi had invariably taken place. They appeared 
to have originated as blind pouches from pre-existing tubules. 




"~ ■*> - - ' ~~-o- ■^T<SejS5J^^?«?^ -'. . ;-. I §^H|^ 




Fig. 43.— Senn's Splint Apparatus for Treating Fracture of Neck of Femur. 




Fig. 44.— Senn's Splint Apparatus Applied ; Pad Making Pressure over 
Trochanter in the Direction of Neck of Femur. 



Liver. — Tizzoni has also observed, in his experiments on dogs, pro- 
duction of new gland-tissue during the healing of wounds of the liver 
and after partial excision of this organ. 



64 PRINCIPLES OF SURGERY. 

Spleen. — The same author studied experimentally regeneration of 
the spleen-tissue, and found that this occurred after partial and complete 
extirpation, the new tissue being made up of elements in connection with 
blood-vessels of the adjacent peritoneum. After complete extirpation 
of the organ the new spleens appear as nodules of a brownish color 
which are attached to the vessels of the peritoneum, and develop around 
new buds of these vessels. The beginning of such a minute spleen 
appears as an accumulation of new loose connective tissue, in the meshes 
of which lymph-corpuscles are found ; later, follicles and pulp-substance 
appear, with a corresponding arrangement of blood-vessels. As these 
little organs always appear about the hilus of the spleen, they cannot be 
supernumerary spleens. After excision of wedge-shaped pieces of the 
spleen, formation of new spleen-tissue has also been observed upon the 
omentum at a point opposite the wound and independently from tissue 
proliferation in the wound. Reproduction of tissue therefore takes place 
in the same manner as in the regeneration of lymphatic tissue. After 
the removal of the entire spleen, tissue proliferation takes place in the 
adjacent blood-vessels, the product of which corresponds with normal 
splenic tissue, and doubtless possesses the same physiological functions. 
As the immediate result of such proliferation, an altered condition of the 
vessels must be accepted, as the blood-vessels of the omentum and peri- 
toneum correspond with the fundus of the stomach. Mayer claimed 
regenerative capacity for the pulp of the spleen, but he ma}^ have been 
deceived by the presence of lymphatic glands of the color of the spleen 
at the seat of extirpation. Picard and Malassez, Bizzozero and Salvioli, 
and finally Tizzoni and Fileti showed that after splenectomy a diminu- 
tion of the blood-corpuscles is observed first, but as the new spleen-tissue 
is produced their number again increases. 

Lymphatic Glands. — Bayer and Bacialli have shown, by their experi- 
mental investigations, that new lymphatic tissue is rapidly produced 
after partial as well as after complete removal of a lymphatic gland. In 
the regeneration of this tissue the adjacent adipose tissue appeared to 
take an active part. According to Bayer, the adipose tissue is first 
infiltrated with leucocytes, while Bacialli saw new endothelial cells and 
lymph-spaces develop from the connective-tissue cells, after having seen 
mitotic figures in the nuclei. After complete extirpation of a lymphatic 
gland, reproduction of lymphoid structure in all probability does not 
take place from any other but lymphatic tissue, and the new gland- 
tissue is the product of tissue proliferation from the cut ends of 
lymphatic vessels. 

Kidney. — The experiments of Tuffier have demonstrated that the 
kidney is endowed with a recuperative capacity which is common to 



GLANDS. 



65 



nearly all of the glandular organs. They show that it is possible to 
successively remove a large part of the normal renal tissue, and that, 
after a certain number of days, the sooner the less renal parenchyma 




Fig. 45.— Wound of Kidney, Fourth Day. (Tillmanns.) 

Large regeneration cells of different forms (ft) ; a, blood extravasation containing new cells (c) 
produced bj' coalescence of leucocytes. 

removed, the specific gravity of the urine and the excretion of urea are 
perfectly re-established, and that compensation was due partially to 
hypertrophy of the remaining parenchyma and partially to the new 




Fig. 46.— Healing of "Wound of Liver, Tenth Day. Havtnack 3, Oc. iii. (Tillmanns.) 

a, young connective tissue ; b, liver-tissue at the margin of the wound, showing fatty degeneration, 
and infiltrated with red and white blood-corpuscles. 

formation of glomeruli, and this happened even in cases of animals in 
which one kidne} T had already been extirpated, and was followed by a 
partial removal of the kidney on the other side. Tuffier, as a result of 



66 PRINCIPLES OF SURGERY. 

his experiments, states that, in animals, from 15 to 23 grains of renal 
gland-tissue are sufficient for two pounds of weight. Estimating the 
weight of the human body at one hundred and forty pounds, from 1200 
to 1500 grains of renal parenchyma, apart from the capsule, which is 
not counted, are sufficient to maintain life. This would amount to about 
one-third or one-fourth of the normal organ. Surgically, therefore, it is 
possible to remove a large part of the kidney, the remaining portion still 
retaining its function ; and in partial destruction of the renal tissue it is 
not necessary to remove the whole organ, and we can be satisfied with a 
partial excision, especially if the condition of the other kidney is not 
known. Partial excision may become necessary in injuries of this organ, 
in circumscribed abscesses, and non-malignant tumors. Successful par- 
tial nephrectomy has been done by Herczel and Kummell, in both 
instances for circumscribed inflammatoiy lesions. 

CENTRAL NERVOUS SYSTEM. 

The central nervous system is built up partly from the mesoblast 
and partly from the epiblast. The stellate and spider-shaped cells are 
derived from the mesoblast, while the neuroglia and the nerve-cells 
proper spring from the neuroblast, a part of the epiblast, which, in the 
embryo, is located nearest the middle axis. The neuroglia represent 
channels of nutrition, which are formed only at a time when the neuro- 
blasts tissues have reached the height of their development. The 
mesoblastic portion of the brain and spinal cord does not increase dur- 
ing the healing of a wound of these parts. In pathological conditions, 
however, as in cases of multiple sclerosis, the stellate and spider-shaped 
elements proliferate so actively that the nerve-cells are completely dis- 
placed by the new product. Many authors have expressed their doubts 
as to the possibility of regeneration of brain-tissue after injury or dis- 
ease, while others have gone to the opposite extreme and claim that 
complete repair can take place in cases of extensive defects. Yoit claims 
that in pigeons he has observed complete restoration of both structure 
and function after extirpation of the entire cerebrum. While large de- 
fects are not repaired, the regenerative capacity of the nervous elements 
cannot be doubted, and such a doubt would come in conflict with a 
general law, Regeneration of the cerebral nervous system comprises the 
production of new ganglia-cells and neuroglia, the latter consisting of a 
fine net-work, sometimes of nervous, at others of basic, substance. 
During the healing of every wound of the brain the observer can satisfy 
himself that the neuroglia possesses a high capacity of reproduction, as 
well-marked karyokinetic changes can be seen during the first twenty- 
four hours after the injury. The new cells are very abundant, and arrange 



CENTRAL NERVOUS SYSTEM. 67 

themselves in groups. More difficult is the demonstration of the same 
changes in the ganglia-cells, but Mondino (1886) and Coen (1887) have 
given descriptions of these cells which leave no further doubt that they 
also multiply by karyokinesis. Klebs has also observed karyokinetic 
figures in the nuclei of ganglia-cells during the repair of injuries of the 
brain. In the embryo, increase of ganglia-cells by karyokinesis has been 
witnessed by Pfitzner, Uskoff, Rauber, Merk, and Cattani. It is true 
that brain wounds heal with some defects, but this applies to extensive 
injuries in which the regenerative capacity of the brain-substance is not 
equal to the emergency ; hence, only a part of the defect is repaired. 
Klebs gives an accurate account of his examination on the reparative 
process in two cases of brain injury, — one recent, the other of long stand- 
ing. Microscopical examination of the tissues from the seat of injury 
in both cases showed that new tissue had been produced. He found many 
new cells from the neuroglia which he is inclined to believe may func- 
tionally take the place of ganglia-cells. The same author made numerous 
experiments on young animals for the purpose of studying the process 
of healing in wounds of the brain. With an aseptic needle the brain 
was punctured. No symptoms followed the injury. The brain was 
examined from two to four days after puncture ; only slight meningeal 
haemorrhage. The needle-track in the brain not closed. Mitotic changes 
were found not in the cells in the immediate neighborhood of the punct- 
ure, but in the cells corresponding to from the second to the fifth row 
from it. In the same place were found an accumulation of resting nuclei. 
Mitotic cell proliferation of injured cells was found completed on the 
fourth day. Ganglia-cells undoubtedly increase in number in the same 
manner. He found no leucocytes in the brain, and believes that those 
that must have been present had been appropriated as food by the cells 
which had undergone karyokinetic changes. The gray matter of the 
surface of the brain is composed of numerous but exceedingly small 
cells, and their numerous connections would indicate great reproductive 
capacity. 

Peripheral Nerves. — When Cruikshank suggested the possibility of 
restoring physiological function in a divided nerve by suturing, his con- 
temporaries regarded the suggestion as an absurdity. Since that time 
the subject of nerve regeneration has engaged the attention of some of 
the best men in the profession, and from the knowledge which has thus 
accumulated it is safe to repeat the statement made by Yan Lair recently, 
that " the surgeon who neglects to suture a divided nerve commits the 
same mistake as he who neglects to reduce a fracture or fails to unite a 
divided tendon." Regeneration of a nerve takes place exclusively from 
pre-existing nerve-fibres. Schwann's sheath isolates the nerve-fibre so 



68 PRINCIPLES OF SURGERY. 

thoroughly from the mesoblast that it would be almost impossible for 
the latter to take any direct or active part in the regeneration of the 
former. The neuroblasts from which tissue proliferation takes place 
are found within the nerve-sheath. Confluence of the new nerve-elements 
within the neurolemma does not take place, as, according to Cattani, 
they receive envelopes from the medulla. Section of a motor fibre is at 
once followed by degeneration of the motor terminal part ; hence, degen- 
eration and regeneration in the divided nerve and the muscles supplied 
by it are parallel processes. Degeneration and regeneration have been 
studied in nerves that were stretched, lacerated, or completely cut across, 
and the histological processes were found almost identical in all of these 
conditions. The study of degenerative and regenerative processes side 
by side in injured nerves has thrown much light upon their minute 
anatomy. The medullated peripheral nerve-fibre is composed essentially 
of Schwann's sheath, the axis-cylinder, and a fluid which appears as a 
periaxial layer. Klebs looks upon this fluid as a sort of nervous endo- 
lymph, which, by virtue of its great mobility, takes part in the nutrition 
of the nerve. The space which contains the fluid, being between the 
axis-cylinder and the sheath, serves not only the purpose of a channel 
for the fluid, but also for the dissemination of movable elements, as, for 
instance, migration corpuscles. Leucocytes are only present in any 
considerable numbers in pathological conditions. Schwann's sheath is 
composed of connective tissue. The large oval nuclei, containing each 
one or two shining nucleoli, which are attached to its inner side, are the 
neuroblasts. It is as yet not definitely settled whether the portion of 
nerve between two of Ranvier's constrictions is composed of one or 
more cells. Reclus accepts Ranvier's theory, that the new nerve-elements 
originate from the axis-cylinder of the central end, and generally from 
Ranvier's ring nearest the section. A single nwelin-fibre is produced 
here, or an axis-cylinder which later is enveloped by myelin. From this 
tube new tubes are formed, finally, from twenty-five to forty in number, 
which approach the peripheral end, insinuate themselves into empty 
Schwann's sheaths or the spaces between them. Klebs is inclined 
to accept the view that such a space is represented by one cell, and 
if several nuclei are present they are the product of nuclear seg- 
mentation. The nuclei must be regarded in the light of peripheral 
nerve-cells. The specific functional contents of a nerve-fibre are the 
axis-cylinder, theendolymph, and medulla. The first two are continuous 
with the neighboring elements, but not so the medullary sheath. The 
medullary sheath is a very complicated structure. The masses of 
fat are held together and are inclosed by a frame-work of keratin. 
Finer keratin threads unite both sheaths in the form of Golgi's spirals, 



CENTRAL NERVOUS SYSTEM. 



69 



which are present in the funnels of Schmidt-Lautermann's medullary 
spaces ; besides, numerous transverse threads are strung out in zigzag 
shape between the sheaths. The constituent parts of the medullary 
portion of the nerve-fibre can disappear separately ; if the medullary 
fat is removed by absorption, the keratin frame-work becomes visible, — a 
condition which is present during the early stages of neuritis parenchy- 
matosa ; if the keratin frame-work is dissolved, the fat appears in drops, 
as can be seen during the degeneration of a nerve after section. The 
axis-cylinder is a pre-existing structure, which, however, can be only 
distinctly outlined against the medullary sheath and endolymph by 
post-mortem influences. Its structure, in the larger medullated fibres at 
least, is not simple, but is composed of fine fibrillse, held together by an 
amorphous, gelatinous substance. Physiologically, this part of the nerve 




Fig. 47.— Tubulae Suture of Van Lair with Decalctfied-Bone Tube. 

Transverse Section. 

a, concentric fissures ; b, radiating fissures ; c, central canal, showing new nerve-fibres. 



must be regarded as a complex of different conductors, which only differ 
by the qualities of motility and sensibility. Regeneration of a periph- 
eral nerve-fibre is a regular typical process, as far as it serves as a 
substitute for lost elements of a nerve. The process resembles the 
physiological growth of a nerve which alwa} T s occurs only in connection 
with the central nervous system. If the separation between the nerve- 
ends exceeds an inch, restoration of its continuity without assistance 
cannot take place. In such an event the ends become bulbous, the 
medullary substance in the distal portion undergoes degeneration, and 
the axis-cylinder becomes more and more indistinct. The same changes 
take place in the nerve-ends after amputation. When a nerve is simply 
divided and there is no loss of substance, the ends remaining in close 
contact, function is established in a remarkably short time. In two 
instances Gluck observed perfect function within twenty-four hours. 



70 



PRINCIPLES OF SURGERY. 



He concludes that the granulation tissues must have been the means of 
conduction in these cases. In his experiments on the sciatic nerve in 
fowls, where he divided the nerve and immediately sutured with catgut, 
function was restored in from fifty to eighty-six hours. Waller and 
Van Lair are of the opinion that regeneration proceeds entirely from the 
proximal end. According to Van Lair, the zone of proliferation extends 
one and one-half to two and one-half centimetres above the divided end, 

and the new material is principally furnished 
by the cortical tubes. The 3 r oung fibres may 
attain a length of from one to even six centi- 
metres ; beyond this distance they require the 
support of empty nerve-sheaths. If such a 
support is not present the new fibres cease to 
grow and undergo atrophy. When there is 
a space between the severed nerve-ends, the 
fibres easily penetrate through the cicatricial 
tissue as long as it is embryonal. Upon this 
observation are based the experiments of Van 
Lair, who secured union between nerve-ends 
widely separated by interposing between them 
a decalcified-bone tube, the new nerve-fibres 
following the Haversian canal or the fissures 
caused by absorption. 

By Van Lair's method a distance of six to 
seven centimetres has been successfully bridged. 
The time required in the repair of such large 
defects depends on the age of the patient, — 
from three to eight months. Colasanti claims 
that degeneration of the peripheral end only 
extends as far as the next Ranvier's ring, while 
Tizzoni found that degeneration extends from 
the seat of injury in both directions, only that 
it is more marked on the distal side. Most 
of the recent writers on the subject assert 
that when a piece of the nerve is resected the entire nerve on 
the distal side undergoes degeneration, while, if the nerve is onty 
divided and the ends are immediately sutured, at least a number of 
the nerve-fibres retain their integrity. Eichhorst and others, who have 
made regeneration of the nerves a special study, are of the opinion 
that the nerve-fibres of both ends participate in the process of repair, 
and that regeneration commences with degeneration. Eichhorst believes 
that regeneration takes place exclusively by splitting of the axis-cylinder 




Fig. 48. —Nerve-fibre in 
a State of Regenera- 
tion Fifty to Seventy 
Hours after Injury. 
(Gluck.) 

A, proliferation of neuroblasts : B, 
spindle-cell, which, becoming con- 
fluent with similar cells from both 
sides, unites the nerve-fibres : C, rows 
of spindle-eells, forming amyelinic 
nerve-fihres ; D, young amyeloid cells, 
formed from nuclei of neurolemma. 



CENTRAL NERVOUS SYSTEM. 



71 



within Schwann's sheath, so that the latter in the course of time becomes 
distended with the product of proliferation. Continuity is restored by 
the central fibrils being pushed outward through the cicatrix to meet the 
peripheral, and coalescence follows. Beneke, on the other hand, traced 
the origin of the new fibres to protoplasm of the neuroblasts, which are 
transformed into delicate fibrils, which become surrounded by a coating 
of myeline, — the future medulla. It is more probable that regeneration 
of a nerve takes place by the latter method. After a trauma reproduc- 
tion of the axis-cylinder always follows. According to a number of 




Fig. 49.— Longitudinal, Section through Nerve Twenty-one Days 
after Injury, showing Medullated and Non-medullated Nerve- 
fibres with Round Cells between them. (Gluck.) 



investigators who have studied this subject, several axis-cjdinders are 
formed within each Schwann sheath, each of which is surrounded by a 
separate medullary sheath. It is difficult to ascertain whether these new 
fibres, growing out of one of the old fibres, again become united some 
distance toward the peripheiy, or whether they remain isolated to their 
point of peripheral distribution. After nerve section the axis-cylinder 
swells at the cut end and becomes striated ; this swelling, however, is not 
an active process, but the result of imbibition of stagnant endolvmph. 
The longitudinal striations and formation of vacuoles which have been 
described by Tizzoni are due to the same cause. The granular appear- 



72 PRINCIPLES OF SURGERY. 

ance is brought about by disintegration of the fibrillse. The old axis- 
cylinder breaks down into isolated fragments, which, in part at least, are 
removed by leucocytes, which at this time have made their appearance. 
With such extensive destructive changes in the axis-cylinder it is 
difficult to conceive how regeneration of this structure could take place 
in the manner described by Eichhorst. The only histological elements 
within the fibre-sheath exempt from degeneration are the nuclei of the 
inner surface of the sheath, the neuroblasts, and from these regeneration 
takes place. 

At the seat of regeneration the nerve is enlarged from the accumu- 
lation of the products of tissue proliferation within the neurolemma 
sheaths. 

The first stage of regeneration of a nerve is initiated b} r multiplica- 
tion of the neuroblasts and increase of protoplasm. The nuclei increase 
to double their normal size and then divide into two or more. Division 
of nuclei probably takes place b}' karyokinesis. The protoplasm is gran- 
ular, and is stained a reddish color with neutral picrocarmine. The 
nerve-fibre originates from the protoplasm, and, according to Tizzoni, in 
the form of separate pieces, around which already can be distinguished a 
medullar}' sheath and transparent contents. In other cases there may be 
a direct connection between the old and new axis-cylinder. Longitudi- 
nal striation of the axis-cylinder probably takes place at a time when the 
fibre has formed a direct connection with distant parts, the seat of active 
physiological processes. Leucocytes have been found within the neuro- 
lemma by Tizzoni and Korybut-Daskiewiez, while Neumann denies their 
presence in this locality. Cattani believes that the}' are present within 
the fibre-sheath after nerve-stretching, and can be found as far as the 
motor ganglia of the cord. Nerves of different function, when united, 
will undergo repair and establish useful conductors for the transmission 
of nerve force. The late Professor Gunn established the correctness of 
this assertion by a series of interesting experiments on dogs. Early 
functional results after nerve suture are often fallacious, as the function 
attributed to sutured nerves may be performed by other nerves which 
reach over such areas; and, again, the peripheral manifestation may be 
the result of physical conduction of the irritation, and apparent motor 
recoveries may be stimulated b} r the action of muscles other than those 
supplied by the sutured nerve. 

NERVE SUTURE. 

Nerve suture was first performed by Baudens in 1836, with negative 
result. The procedure was revived b}' Nelaton in 1863, and the follow- 
ing year by Langier. The first operations were made with fine-silk 



NERVE SUTURE. 73 

sutures, which were not cut short, and subsequently came away by suppu- 
ration. 0. Weber advised the uniting of the nerve-ends by passing the 
sutures not through the nerve-substance, but only through the connective 
tissue surrounding the nerve, — the paraneural suture. Experience, how- 
ever, has shown that transfixion of the nerve*ends by the sutures does 
not give rise to pain, and does not interfere with the normal reparative 
processes, and at the same time, by resorting to this direct method of 
suturing, more perfect coaptation is secured. In the case of large nerves, 
it is advisable to re-enforce the direct sutures with a number of para- 
neural sutures. The best material for the sutures is aseptic catgut. 
An ordinary sewing-needle with a dull point is preferable to a surgical 
needle, as it is more sure to pass through the nerve without injuring the 
fibres. 

From one to three direct sutures, according to the size of the nerve, 




DirectSubxro 



Ittra-nsural 
Suture 



Fig. 50.— Nerve Suture, showing Application of Direct and Paraneural 

Sutures. 

are applied, and from three to six paraneural sutures. The needle is 
passed straight through the nerve on each side, one-eighth to one-fourth 
of an inch from the ends, and cure must be exercised, in t} T ing the sutures, 
to bring the cut surfaces in accurate apposition, and not to tie the 
sutures too tightly, as b}^ doing so the nerve-ends are liable to become 
displaced b} T overlapping. In tying the paraneural sutures the neces- 
sary precautions must be taken to prevent the margins of the sheath 
from insinuating themselves between the nerve-ends. 

Primary Nerve Suture. — A primaiy nerve suture is one used to unite 
a nerve immediately or soon after the injury has occurred, and before 
any degenerative changes have taken place. It should always be resorted 
to in the treatment of accidental wounds where one or more nerves have 
been divided, also where in operations a nerve has been divided accident- 
ally, and, finallv, in cases where a neurectomy for pathological conditions 
cannot be avoided. The results after primary suture have been very 



74 PRINCIPLES OF SURGERY. 

satisfactory. Brims lias collected 71 cases from different sources, and in 
more than 33 per cent, of the number function was restored. As sup- 
puration in a wound where a nerve has been sutured would, in all prob- 
ability, cause tearing out of the sutures and displacement of the nerve- 
ends, it is of the greatest practical importance to secure for such wounds 
an aseptic condition and to obtain primary union throughout, and con- 
sequently no provision for drainage should be made. If the wound- 
surfaces cannot be approximated, and a greater or less space has to fill 
up by granulation, a bundle of catgut threads can be used for a capillary 
drain, in order to avoid tension from the accumulation of blood or the 
primary wound-secretion. 

Secondary Nerve Suture. — When a divided nerve fails to unite the 
ends become bulbous, are usually found imbedded in a mass of cicatricial 
tissue, and separated from each other from one to two or more inches. 
The bulbous enlargement of the proximal end remains permanently and is 
often a useful guide to the nerve in cases requiring secondary nerve suture. 
Function below the point of division is complete^ lost; the distal por- 
tion of the nerve itself, beino- no longer in connection with the central 
nervous system, undergoes degeneration, and the muscles supplied by the 
injured nerve become atrophic and useless. The reuniting of such a 
nerve is done by the secondary suture. Experience has shown that 
function can be restored by this procedure years after the injury. 
Jessop vivified the nerve-ends and applied sutures nine years after in- 
jury of the median nerve, and restored function. Langenbeck sutured 
the sciatic nerve two years after division ; sensation returned in three 
daj r s, and, later, motion. As a rule, sensibility returns first after nerve 
suture, followed considerably later by restoration of motor function. 
The most speedy restoration of function, both sensory and motor, after 
secondary suture is reported by Tillaux. He operated on the median 
nerve three years after division. The ends were found imbedded in a 
cicatrix and separated from each other four centimetres. The ends were 
vivified and sutured. He claimed that plrysiological function was re- 
stored completely three hours after the operation. There can be no 
doubt of the ultimate recovery of nerve function in this case, but that 
this should have been attained in three hours appears next to impossible. 
Enough has been said to show that secondary nerve suture can be re- 
sorted to with good prospects of success years after an injury, but for 
well-known reasons it should not be postponed after it has become evi- 
dent that union has failed to take place. Unnecessary delay is danger- 
ous, because when a nerve has become permanently disconnected from 
the central nervous system muscular degeneration goes hand in hand 
with degeneration of the distal portion of the nerve, and the longer the 



NERVE SUTURE. 75 

operation is delayed the greater the length of time required to complete 
the regeneration of the nerve and the muscles. The first secondary 
nerve suture was made by Nelaton in 1865. In Germany the first oper- 
ation was made by Gustav Simon in 1816, and he was followed by Lan- 
genbeck the following year. In 1884 Brims found 33 recorded cases, 
and in 24 of this number the result was satisfactory. As a rule, sensa- 
tion returned gradually in from two to four weeks, while motion did not 
return until three weeks to three months after the operation. Complete 
restoration of function was seldom completed until half a year to one year 
after the operation. As in cases which require secondary suture the nerve- 
ends are sealed with a mass of cicatricial tissue, it is always necessary to 
resect the ends, after which the sutures are applied in the same manner 
as in primary nerve suture. Both nerve-ends must be freed from all 
cicatricial adhesions before approximation is attempted, and, if this 
cannot be readily done on account of previous retraction, both ends are 
carefully stretched and sufficient elongation secured so as to prevent any 
tension upon the sutures. A great deal can be done to prevent tension, 
by placing the limb in such a position as will relax the nerve ; for in- 
stance, flexion of the hand and forearm in suturing the ulnar, median, or 
musculo-spiral, and flexion of the leg and extension of thigh after re- 
uniting the sciatic. The position of the limb most favorable for the 
union of a sutured nerve is best secured by a plaster-of-Paris dressing, 
which is allowed to remain not only till the external wound is healed, but 
until the nerve has firmly united. When a nerve has suffered a consider- 
able loss of substance at the seat of injury it is often found impossible to 
bring their ends in contact by nerve-stretching and position of limb, and 
in such cases restoration of continuity becomes an exceedingly difficult 
task. 

Letievant suggested that the defect in such cases should be cor- 
rected by a neuroplastic operation. He proposed that a flap should be 
taken from each end sufficiently long that, when turned toward each 
other they could be sutured at the middle of the defect, thus making a 
connecting bridge of nerve-tissue between the separated nerves. (Fig. 
51.) As could be expected, in a case where he performed this operation 
the result was negative. In a case operated on by Tillmanns after this 
method, partial restoration of function was established three and a half 
months after the operation. The success in this case was probably not 
the result of conduction of nerve-force along the fibres of the flaps, but 
the production of new fibres across the gap, perhaps through the 
tissues composing the temporary bridge. The same author devised for 
a similar class of cases what he calls cross sutures (Fig. 52), where the 
nerves are cut at a different level and the ends separated too far for any 



76 



PRINCIPLES OF SURGERY. 



direct method, suitable in the median and musculocutaneous in the arm 
or the median and cubital nerve in the forearm. The two longer ends 
are united by direct suture and the shorter ones grafted into the adjoin- 
ing trunk. The success of this operation is based on the physiological 



1. 



Fig. 51.— Neuroplasty, after 
Letievant. 

A, upper end ; A', lower end ; H, H', flaps turned 
toward each other; D', B', suture of the two flaps; 
D, B, level of section of flaps. 



Fig. 52.— Cross Sutures. (Tillmanns.) 

1. The ends A B and C D are too far apart to be 
sutured : the upper end (C) of the nerve will be united 
with the lower end (B) of the other nerve. 2. Com- 
pleted suture ; the ends A D are implanted into the 
adjoining nerve-trunk. 



law of the conductibility of nerve-fibres. This operation has resulted 
successfully in a number of instances in the human subject. From his 
experiments on animals, Gluck came to the conclusion that nerve defects 
could be corrected hy transplantation of nerves ; that is, inserting a piece 
of nerve from an animal, corresponding in size to the nerve to be reunited, 



NERVE SUTURE. 77 

between the nerve-ends, and uniting it with them with sutures. He re- 
ports a number of successful experiments on chickens, filling the gap 
with a nerve taken from rabbits. Philipeaux and Vulpian, from their 
own researches, came to the conclusion that a transplanted nerve always 
degenerates and disappears, and that restoration of structure and func- 
tion only takes place by regeneration from the nerve-ends. It is probable 
that the methods of nerve restoration devised by Letievant and Gluck 
are useful in reuniting separated nerve-ends in the same manner as the 
suture a distance of catgut suggested by Assal^. The interposition of 
an aseptic, absorbable substance like catgut or nerve-tissue serves as a 
temporal scaffolding for the products of tissue proliferation from the 
nerve-ends, which at the same time determines the direction for the new 
material, providing the shortest route to meet the same material from the 
other side. When catgut is employed two or three sutures are used, so 
that the combined size of the strings will at least approximately corre- 
spond to the size of the nerve. Van Lair, who believes that regeneration 
of a nerve takes place exclusively from the proximal end, resected a piece 
of the sciatic nerve in dogs, and then sutured both ends of the nerve to 
the ends of a decalcified-bone tube, which in length corresponded to the 
section of nerve removed. From the results of his experiments, ten in 
number, he became satisfied that continuity of the nerve was restored 
by the new nerve-fibres from the proximal end growing into the tunnel, 
bridging the defect in a comparatively short time, as they had no resist- 
ance to overcome, and uniting with the end of the nerve on the opposite 
side of the tube. It appears to the author that this method of over- 
coming the difficulties of reuniting nerve-ends widely apart is not only 
an ingenious procedure, but, if applied in practice, promises better re- 
sults than any other method heretofore proposed. In certain cases where 
the distal end cannot be found, or where the separation is so great that 
none of the methods of approximation so far devised hold out any in- 
ducements of a successful issue, Letievant suggested the idea of grafting 
the central end upon the intact trunk of a neighboring nerve. This 
operation failed in his hands, but Tillaux and Tillmanns, slightly modify- 
ing the method, were successful. In Tillmanns' case the ulnar nerve 
had been divided, the ends were found separated 4-J centimetres, and the 
proximal end was grafted upon the median nerve. Sensation returned 
in a month, and by using electricity and massage recovery was complete 
a year later. Nerve-grafting, as advocated by Letievant, should only be 
resorted to after implantation of a decalcified-bone tube between the 
nerve-ends has been tried and proved a failure, or in cases where the 
defect is very extensive, or, finally, if, after the most diligent search, the 
distal end cannot be found. Restoration of function does not always 



78 PRINCIPLES OF SURGERY. 

follow after the continuity of a nerve has been restored by operative 
measures. Ehrmann has reported such a case. The radial nerve was 
divided below the elbow and failed to unite. Complete paralysis of all 
the muscles supplied by this nerve. After the lapse of seven months the 
nerve was exposed, and the ends, which were 5 centimetres apart, were 
vivified and sutured. Seven months after the operation, no improvement. 
The nerve was again exposed at the former site of operation, and it was 
found that union had taken place, but the nerve was compressed by a 
firm cicatrix 2 or 3 centimetres in length. The nerve was relieved from 
its imprisonment, and when the faradic current was applied all the 
muscles supplied by the nerve responded. Four months later, complete 
recovery. This case reminds us of the importance of securing healing 
of the nerve and wound with as little cicatricial tissue as possible, which 
can only be done by absolute asepsis and careful attention to suturing 
of the wound. 



CHAPTER III. 

Inflammation. 

The subject of inflammation is one of deep interest both to the stu- 
dent and practitioner, as it initiates the former into the field of general 
and special pathology, and the latter meets with it daily in some form in 
his practice. We have already set apart from inflammation those numer- 
ous processes by which injuries or defects are repaired without destruc- 
tion of any of the new tissue-elements which have been described in the 
first chapter under the head of Regeneration. From a scientific and 
practical stand-point, it is exceedingly important to draw a distinct line 
between the series of tissue changes which attend regenerative processes, 
uncomplicated by the action of pathogenic bacteria, and true inflamma- 
tion, which is always caused by the presence of one or more kinds of patho- 
genic microbes. As compared with true inflammation it has been custom- 
ary for quite a number of years to speak of regeneration as a plastic or 
regenerative, inflammatory process ; but the term inflammation in the 
future should be limited to the series of histological changes which ensue 
in the living body from the presence and action of specific microorgan- 
isms, while the word regeneration should be used to designate the histo- 
logical changes which take place in tissues which have been primarily in 
an aseptic condition or have been rendered so after the inflammation has 
subsided. From this it will be seen that the study of inflammation is 
intimately and inseparably associated with a consideration of the new 
science of bacteriology. For most forms of inflammation the presence 
of a specific microorganism has been demonstrated, and its etiological 
relationship established by cultivation and inoculation experiments; and 
in the few inflammatory diseases where no such positive proofs can be 
furnished we have, from analogy and circumstantial evidence, reason to 
suspect the presence of undiscovered microbes. Inflammation, in the 
widest and most comprehensive meaning of the word, should be made to 
embrace pathological conditions which are caused by the action of patho- 
genic microbes or their ptomaines upon the histological elements of the 
blood and the fixed tissue-cells. A correct definition of inflammation, 
which should embody the etiological, anatomical, and pathological char- 
acteristics of the disease from our present knowledge of the subject, 
cannot be given, as many important points connected with the compli- 

(79) 



80 PRINCIPLES OF SURGERY. 

cated processes await explanation by future investigation. Sanderson 
defines inflammation as " the succession of changes which occur in a living 
tissue when it is injured, provided that the injury is not of such a degree 
as at once to destroy its structure and vitality" As we have restricted 
the term inflammation to the succession of changes which occur in a 
living tissue from the action of pathogenic microbes or their ptomaines, 
this definition would cover processes which, for reasons already given, 
we have considered as instances of tissue proliferation unattended b}^ 
an}'- of the characteristic features of inflammation. J. Bland Sutton uses 
the term inflammation in a more restricted sense in coining the following 
definition : " It is the method by winch an organism attempts to render 
inert noxious elements introduced from without or arising within it." As 
nothing is said of the method, the most important part of the definition, 
it certainly cannot be said to cover the whole ground. The conception 
of the true nature of inflammation for the present, at least, must remain 
symptomatic. As a rule, inflammation subsides as soon as the primary 
cause has disappeared or has been rendered inactive, as is well shown by 
the spontaneous disappearance of febrile disturbances in the general in- 
fective diseases, and the subsequent rapid repair of the local lesions 
which characterize them. If an acute inflammation become chronic, 
either from a diminution of the quantitative or qualitative intensity of 
the primary cause, or from the tissues becoming accustomed to its action, 
it is sometimes diflicult to tell whether the primary cause has disappeared 
or has ceased to act, or whether it is still present and active. In chronic 
inflammation the most reliable indications of the presence and potency 
of the primary bacterial cause are acute exacerbations, as chronic inflam- 
mation only consists of a series of acute inflammatory processes which 
repeat themselves at longer or shorter intervals. The differences between 
an acute and chronic inflammation are not in kind, but in degree. The 
complicated processes which characterize inflammation can be studied 
most profitably by considering separately and conjointly the sj'mptoms 
to which the} 7 give rise, which Galen enumerated as calor, rubor, dolor et 
tumor, to which may now be added the functio leesa of modern authors. 
The study of the objective and subjective manifestations of inflammation 
should be preceded hy a short description of 

THE HISTOLOGICAL ELEMENTS WHICH ARE DIRECTLY CONCERNED 
IN THE INFLAMMATORY PROCESS. 

Capillary Vessels. — The most important histological changes in in- 
flammation, acute or chronic, transpire within, and in the immediate 
vicinity of, capillary vessels. The smallest arteries and veins, the ves- 
sels on either side of the capillaries, undergo changes, and the disturb- 



HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 81 



ance of circulation within them constitutes a part of the picture of in- 
flammation, but it is in the capillaries that the most serious disturbances 
occur; it is here where the noxse are brought in closest contact with the 
para- vascular tissues, and it is here where the inflammatory exudation 
and transudation take place. The capillaries are minute vessels, or rather 
channels, which connect the arteries and veins, the walls of which are 
composed of a thin, elastic, endothelial membrane ; that is, a single layer 
of nucleated cells held together by an amorphous cement-substance. In 




Fig. 53. —Capillary Vessels of the Frog's Mesentery, Stained with Ni- 
trate of Silver only ; the Wall of the Vessel is Viewed from the Sur- 
face, and is Seen to Consist of Elongated Endothelial Cells, Marked 
by their Outlines only ; the Nucleus of the Individual Cells is not 
Shown. (Klein.) 

silver-stained specimens the cement-substance appears as dark lines 
which outline the boundaries of the cells. 

The shape of the cells is more or less elongated, with pointed ex- 
tremities, and their outline smooth or sinuous. The nuclei of these cells 
are oval, situated either about the middle of the cell or near one ex- 
tremity. The nucleus contains within a well-defined membrane a net-work 
of chromatin threads, but no nucleolus. When the capillaries undergo 
alteration and distention, as in inflammation, the cement-substance yields 
in many places ; in consequence of this minute openings appear, called 
by Arnold stigmata, which become gradually enlarged into stomata. 



82 PRINCIPLES OF SURGERY. 

Winiwarter found that by injecting inflamed capillaries the contents of 
the vessel escaped through these openings. Through these openings 
emigration of leucocytes takes place, and when the inflammation is very 
intense the red corpuscles escape, — a process which Strieker has named 
diapedesis. If the capillary vessels, through which emigration has been 
going on, be stained with nitrate of silver, it is seen that the emigration 
is limited to the interstitial cement-substance of the endothelial wall. 
(Purves.) 

Klein has shown that the walls of all capillary vessels in the adult 
state form a direct connection with the process of the connective-tissue 
corpuscles of the surrounding tissue, — a matter of great interest in 
studying the relationship between the capillary vessels and the sur- 
rounding connective-tissue spaces. 

Blood-corpuscles. — The blood-corpuscles frequently serve as carriers 
of the microbic cause of the inflammation ; they block the lumen of 

inflamed capillary vessels, partially or completely, 
and constitute the histological elements of the 
primary exudation. The element of the blood 
which is more intimately associated with the 
histology of inflammation is the 

I. Leucocyte, op White Blood-corpuscle. — 
This is a nucleated, spherical, transparent mass 
of protoplasm, without a limiting membrane or 

fig. 54.— leucocyte, envelope. Heitzmann made the. discovery that 
showing Reticulum of ., . „„ ■ „_ -i <? , . , „ . * 

Protoplasmic Strings. it IS composed 01 a reticulum of protoplasmic 

( strings, with a hyaline substance in the meshes. 

The nucleus shows a similar structure, and its net-work is continuous 

with that of the cell-body. Strieker and Klein, as well as a number of 

other histologists, have adopted Heitzmann's views in reference to the 

minute anatomy of the leucocyte. The reticulated structure is well 

shown by staining with chloride of gold, which stains the protoplasmic 

strings, but not the interstitial substance. The leucocyte is endowed 

with intrinsic power of locomotion, — amoeboid movements, — a function 

which is performed by the reticulum. Wharton Jones discovered motion 

of protoplasm in leucocytes of human blood as early as 1846. In 1862 

Haeckel showed that the white blood-corpuscles absorb pigment-granules, 

— a process which can only take place b}^ amoeboid movements, which by 

change of form of cell bring the foreign material into its interior by 

inclusion. These observations enabled Colin heim to demonstrate later 

that the white blood-corpuscles found in the vascular spaces of the cornea 

were derived from the blood ; in other words, to establish the fact of 

emigration of leucocj^tes through the inflamed wall of capillaries. The 




HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 83 




B 



amoeboid movements of the colorless corpuscles can be well observed for 
hours in the moist chamber on the warm stage. 

The movements of a leucocyte are peculiar. The first effort consists 
of a protrusion of a hyaline film. This is withdrawn and another is 
protruded ; in the next moment this is diminished to a very minute 
process, whereas, on the opposite side, a new, broad process appears. 
After this the corpuscle is seen to throw out processes of various length 
and thickness, and thus to alter its shape in a considerable manner. Ity 
virtue of the amoeboid movement of leucocytes they move from place to 
place independently of the blood or plasma current. This independent 
locomotion enables them to pass through the small opening in the wall 
of inflamed capillaries, and, after they have reached the para-vascular 
tissues, to travel along connective 
tissue spaces until arrested by some 
mechanical obstruction. If pigment- 
material, in a finely-divided state, is 
mixed with blood, either before or 
after withdrawing it from the vessels, 
the projections thrown out by the 
leucocytes inclose the particles 
brought in contact with it, and the 
granules reach in this manner the 
interior of the leucocytes, and are 
variously distributed according to 
the shape and movements of the pro- 
toplasm. Microbes reach the in- 
terior of the leucocytes in the same 
manner. In cases of intra-vascular 
infection the emigration corpuscles 
convey with them the microbes through the wall of inflamed capillaries 
into the tissues surrounding them. 

2. Red Blood-corpuscle.— The colored blood-corpuscle serves less 
frequently as a carrier of microbes than the leucocyte, as it does not 
possess as active amoeboid movements. For the same reason it is not 
found so constantly as a component part of the inflammatory exudation, 
as its transit through the capillary wall is a more passive process, and is 
accomplished principally by the vis a tergo in case the stomata are suffi- 
ciently large to permit its passage. Leonard has recently demonstrated 
the amoeboid movements of the red corpuscles by instantaneous micro- 
photography. The movements extended over half an hour upon the 
warm stage, and the pictures obtained are well shown in Fig. 56. The 
presence of numerous colored corpuscles in the exudation is an indica- 




Fig. 55.— Change of Forms of a Moving 
Leucocyte by Amceboib Move- 
ments. (Klein.) 



84 



PRINCIPLES OF SURGERY. 



tion of great acuity and intensity of the inflammation, — conditions 
causing serious and extensive alterations of the capillary wall. The 
escape of whole blood through a capillary vessel greatly damaged by the 
cause of the inflammation is called rhexis. 

3. Third Corpuscle.— A third cellular element in the blood, the 
third corpuscle, was discovered by Max Schultze, in 1865. He described 
it as a small, colorless sphere or granule. Elaborate descriptions of 
this corpuscle were given by Hayem, in 1878, and Bizzozero, in 1882. 
Hayem, from his observations, believed that these minute structures 
represented young colored blood-corpuscles, and hence named them 
hsematoblasts. Bizzozero entered his protest against this theory and 
called them blood-plates (BlutplattcJien). Under the microscope they 
appear as minute, faintly-colored blood-corpuscles. They seem to 
possess a little stroma like the red blood-corpuscles, but contain no 







Fig. 56.— Amoeboid Movements of Red Blood-corpuscles, after Leonard. 



nucleus and are devoid of any cell-membrane. What appears as a 
nucleus is, according to Hayem, an optical defect. 

Hayem estimates that they are forty times more numerous in man 
than the leucocytes, and twenty times more abundant than the colored 
corpuscles. As there has been no positive proof furnished that the third 
corpuscle is an embryonal red blood-corpuscle, and as it has been shown 
that blood-corpuscles are produced from the fixed cells of blood- 
producing organs, as, for instance, the spleen and medullary tissue, it is 
advisable not to apply to it the term hamiatoblasts, but to distinguish it 
from the remaining two morphological elements of the blood numerically 
by calling it the third corpuscle. Under a higher power the third 
corpuscle can be readily recognized in the blood-stream of capillary 
vessels in the mesentery or web of a frog. In blood withdrawn from a 
vessel it is destroyed as soon as coagulation sets in ; hence it disappears 



HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 85 



almost immediately after it leaves the blood-vessel. In order to study it 
outside of the body, means must be employed to prevent coagulation, 
which can be done by mixing the blood with the following solution, 
recommended by Hayem : — 

Distilled water, 200.00 cubic centimetres. 

Sodic chloride, 1.00 gramme. 

Sodic sulphate, 5.00 grammes. 

Mercury bichloride, 0.50 gramme. 

From a needle-puncture the blood is allowed to mix with the solu- 



B< 







— A 

B 




Fig. 57. {Eberth and Schimmclbusch.) 

1. Third corpuscle. A. natural appearance when seen on surface and on edge ; B, C, C, D, and E, 
appearance presented by them during coagulation. 2. Shows the little heaps of granules formed hv them 
after coagulation (Hayem). 3. A small blood-vessel as stasis is approaching. A, third corpuscles in 
periphery of stream ; B, colored blood-corpuscles; C, leucocyte. 

tion in the proportion of about 1 to 20 up to 1 to 100. In this mixture 
the third corpuscle will retain its shape and size for twelve to twenty- 
four hours. The third corpuscle is a fibrin-producing structure, and, as 
such, it takes an active part in the formation and growth of intra-vascular 
blood-clots. The white mural thrombus, produced intra vitam, is com- 
posed almost exclusively of this element of the blood. If, from a trauma 
or disease, the endothelial lining of a blood-vessel is injured and the 
smooth surface becomes uneven, the third corpuscles, floating in the 
peripheral portion of the axial current, come in contact with projecting 



86 PRINCIPLES OF SURGERY. 

points, and are arrested and become attached to the vessel-wall, layer 
after laj'er is added, and in this manner the mural thrombus is formed. 
On the surface of recent wounds they appear in large numbers, lose their 
fibrin ferment, and give rise to the formation of fibrin, which acts both 
as an haemostatic and temporary cement-substance. In inflammation the 
third corpuscle escapes through the capillary wall in the same manner as 
the red corpuscles, but, on account of its smaller size, its peripheral loca- 
tion in the blood-stream, and its greater abundance, it is numerically 
more abundant in the inflammatory exudation. The fibrin in inflamed 
tissues is undoubtedly derived largely from this source. 

4. Fixed Tissue-cells. — The fixed tissue-cells behave differently in 
the inflamed part, according to the intensity and nature of the primary 
microbic cause. The microbes, or their ptomaines, may possess such 
intense local toxic properties as to destroy their vitality directly when 
the inflammation results in necrosis, as is the case in the centre of an 
ordinary furuncle, and on a larger scale in cases of progressive phleg- 
monous inflammation. The fixed tissue-cells may be destroyed by 
starvation, by the primary inflammatory exudation being so abundant as 
to obstruct the circulation in the inflamed part. If the cause of the in- 
flammation is less intense, as is the case in chronic inflammation, the 
fixed tissue-cells are brought in direct contact with the microbes which 
produced the inflammation, and active tissue proliferation is^ the result, 
and this furnishes the bulk of the inflammatory product. The histo- 
logical structure of tubercle furnishes a good illustration of the part 
taken by the fixed tissue-cells in chronic inflammation. In chronic sup- 
purative inflammation the fixed tissue-cells are first transformed into 
embryonal tissue, and, as the protoplasm of the new cells is destined 
by the ptomaines of pus-microbes, the}^ are converted into pus-corpuscles. 
A passive role in the inflammatory process was assigned to the fixed 
tissue-cells by Boerhave, who regarded stasis as the essential feature of 
inflammation ; by Andral, who believed that hypersemia was the char- 
acteristic pathological condition in an inflamed part; and by Rokitansk}", 
who taught that exudation constituted the most important element in 
all inflammatory lesions. Yirchow located the primary seat of inflam- 
mation in the fixed tissue-cells, and asserted that nutritive or formative 
irritation occurred in them independently of vessels or nerves. He 
maintained that, the more the cells were disposed to take up nutritive 
material, the greater the danger that the} r themselves would be destro3 T ed. 
Remaining faithful to the doctrine that inflammation is only caused by 
the presence and action of a specific microbic cause, we shall find that, 
the more acute the process, the less the probability that the fixed tissue- 
cells take an active part, and that, the more chronic the inflammation, the 



SYMPTOMS OF INFLAMMATION. 87 

greater the amount of the new material that has been derived from the 
fixed tissue-cells, and the smaller the quantity of vascular exudation. 

SYMPTOMS OF INFLAMMATION. 

The structural changes caused by inflammation give rise to a char- 
acteristic complexus of symptoms, — pain, redness, swelling, heat, and 
suspension, — diminution, increase, or perversion of function. These 
symptoms vary in intensity, according to the nature of the primary 
cause and the anatomical structure and location of the tissues affected. 
One or more of the symptoms enumerated may be absent, when the 
existence of inflammation must be ascertained by a more careful study 
of those presented. In acute inflammation the symptoms appear in 
rapid succession or almost simultaneously, while in the chronic form 
they come on slowly, often almost insidiously, and frequently one or 
more are wanting, even when the disease is far advanced. The number 
and intensity of the individual symptoms vary not only according to the 
virulence of the primary microbic cause, but are also modified by the 
resisting capacity of the individual and the tissues affected. We speak 
of a complete or partial immunity to certain microbic diseases, and of a 
general or local, hereditary or acquired, disposition. For diagnostic 
purposes the symptoms must be studied individually and collectively, 
and with special reference to their etiology and the location and structure 
of the inflamed tissues or organ. 

(a) Pain. — Pain is one of the most variable symptoms of inflamma- 
tion. It is caused by traction or pressure to which sensitive nerve-fila- 
ments are subjected in the inflamed tissues, and probably, also, in some 
instances, at least, by extension of the inflammatory process to the 
structure of the nerves themselves. Some patients are more sensitive 
to pain than others. The same extent and degree of inflammation of the 
same part giving rise to sensation of discomfort in a torpid person may 
cause excruciating pain in patients with a nervous temperament. As 
the degree of pain will depend largely upon the number of sensitive 
nerves present in the inflamed area and the amount of exudation, we 
would naturally expect to find pain a prominent symptom in inflamma- 
tions of unyielding tissue freely supplied by sensitive nerves. This, as 
a rule, is the case. Pain is a distressing symptom in cases of phleg- 
monous inflammation of the fascia and tendon-sheaths of the fingers and 
palm of the hand. Pain is the most conspicuous symptom in periostitis 
and inflammation of the serous membranes. Wherever the inflammatory 
exudation appears rapidly in parts freely supplied with sensitive nerves, 
pain from tension appears as one of the foremost symptoms, and con- 
tinues without intermission until tension is relieved. In acute suppu- 



88 PRINCIPLES OF SURGERY. 

rative osteomyelitis intense pain is present from the very commencement 
of the disease, and continues unabated until tension is removed by 
operative procedures, or by escape of inflammatory product, through 
some defect in the bone, into the more yielding paraperiosteal tissues. 
The pain is throbbing, sometimes synchronously, with the pulse in acute 
circumscribed phlegmonous inflammation. It is sharp and lancinating 
in inflammation of serous membranes. It is described as a burning 
sensation in inflammation of the skin. The pain is of a dull, aching, 
boring character in deep-seated inflammation, especially in the interior 
of bone. Nocturnal exacerbation of pain is a common occurrence, and 
seldom absent in painful syphilitic affections. The pain is not always 
referred by the patient to the seat of inflammation, as in the early stages 
of coxitis it is not in the hip, but over the inner aspect of the knee, and 
in inflammatory affections of the nerves the pain radiates along the 
peripheral branches, and is usually felt most severely some distance from 
the seat of the disease, at points supplied by the peripheral branches. 
In ascertaining the existence and exact location of a deep-seated inflam- 
mation, tenderness is a more valuable symptom than spontaneous pain. 
Tenderness is the pain elicited by pressure. If the inflamed part is 
tender on pressure and accessible to palpation, the area of tenderness 
will correspond to the extent of the inflammation. During the begin- 
ning of an attack of phlegmonous inflammation the surgeon is able to 
locate the affection accurately by searching for the point where the 
tenderness is most acute, and the same symptom will indicate to him, 
earlier than any other, the direction in which the process is extending. 
In periostitis the area of tenderness will show whether the inflammation 
is circumscribed or diffuse. The existence of circumscribed points of 
tenderness about the epiphyses of the long bones is almost a certain in- 
dication of central osseous tuberculosis, and, at the same time, furnishes a 
reliable guide in their early operative treatment. Firm pressure relieves 
pain in nervous hysterical patients, while it aggravates it when it is 
caused by inflammation. On the other hand, superficial pressure made 
with the tips of the fingers increases the suffering in parts the seat of 
functional disturbance, while it does not materially affect the pain 
resulting from inflammatory lesions. 

(b) Redness. — The composition of normal blood is admirably 
adapted for the passage of this fluid through capillary vessels. As long 
as the relation of corpuscular elements to the blood-plasma remains 
normal, and the intima of the blood-vessels remains intact, and the vis a 
tergo is adequate, there is no tendency to capillary obstruction. If the 
capillary circulation in the mesentery of a frog is examined under a 
microscope, there is no difficulty in distinguishing two currents, — the 



SYMPTOMS OF INFLAMMATION. 89 

axial and peripheral. The axial, or central, current is rapid, and conveys 
the red corpuscles, which have the same specific gravity as the blood- 
plasma, while the peripheral current between the axial and vessel-wall 
is considerably slower, and in this current the colorless corpuscles are 
conveyed, their rotating motion being due to their coming in contact 
with the wall of the vessel. D. J. Hamilton has shown, by numerous 
experiments, that, in fluids holding in suspension solid particles passing 
through capillary tubes, the heaviest particles are carried along the 
central current, while those specifically lighter than the fluid seek the 
peripheral current. The leucocytes are specifically lighter than the fluid 
in which they are contained ; hence they are forced into the space be- 
tween the axial current and the vessel- wall (Fig. 57, C). The third cor- 
puscle, probably for the same reasons, moves also in the peripheral 
stream. The colorless corpuscles accumulate more in the peripheral 
stream when the current is feeble than when it is rapid. This fact is of 
great importance in the study of the altered circulation when the capil- 
lary vessels are in a state of inflammation. The accumulation of color- 
less corpuscles in the peripheral stream in inflamed capillary vessels, 
according to Thoma, Eberth, and Schimmelbusch, is owing to the slow- 
ness of the current, which, although insufficient to propel the specifically 
light, colorless corpuscles, is still competent to force onward the less- 
resisting and specifically heavier-colored corpuscles. 

Eberth and Schimmelbusch state that in the vessels of a warm- 
blooded animal four kinds of stream are noticed, in accordance with its 
velocity: (1) the normal stream, in which the axial current and periph- 
eral zone are readily recognizable; (2) a slow stream, in which the 
leucocytes accumulate in the periphery ; (3) a still slower stream, in 
which the third corpuscles also leave the axis and accumulate in the 
periphery, and in which, these observers assert, the leucocytes become 
less numerous; and (4) a stream so slow as to approach stagnation, in 
which all the elements of the blood are indiscriminately mixed. From 
the above it can be seen that all general and local conditions which tend 
to diminish the velocity of the blood-current in the capillary vessels are 
productive of accumulation of tUe colorless corpuscles and of the third 
corpuscles in the peripheral stream, — a condition which greatly aggravates 
the existing local impediments to capillary circulation, and when well 
advanced, by encroaching more and more upon the central stream, will 
result in complete stasis. Temporary hyperemia of a part or organ is 
of frequent occurrence, and is often the result of abnormal innervation. 
The influences of the nervous s} T stem — particularly of the sympathetic 
nerves — over the circulation are familiar to eveiy student of phj^siology. 
Temporary hyperemias and anaemias of certain parts or organs of the 



90 PRINCIPLES OF SURGERY. 

body — the result of abnormal innervation of the vaso-dilators or vaso- 
constrictors — frequently bring about vascular changes which predispose 
to the localization of the essential microbic cause of inflammation. 
Injury to nerves, mental excitement or depression, and exposure to cold 
are potent factors in the production of temporary vascular disturb- 
ances. Two forms of active hyperemia, due to faulty innervation, must 
be recognized. When caused by a paralysis of the vaso-constrictors it is 
described as hypersemia of paralysis. A classical demonstration of this 
form of hypersemia was furnished by Claude Bernard by his experiment, 
which consisted of division of the cervical sympathetic in the rabbit, 
which was invariably followed by marked hypersemia and dilatation of 
the blood-vessels in the ear on the corresponding side. When the vaso- 
dilators are irritated by mechanical or electrical stimulation the arterioles 
dilate and the part presided over by the affected nerve becomes hyper- 
semic, and the condition of the circulation is known as hypersemia of 
irritation. A good illustration of this form of hypersemia can be pro- 
duced by stimulation of the chorda tympani nerve, which, as was shown 
first by Claude Bernard, always produces dilatation of the vessels in the 
submaxillary gland. Passive hypersemia is caused by mechanical con- 
ditions which interfere with the return of venous blood. .Ligation of a 
vein furnishes the simplest variety of this form of venous congestion. 
Thrombo-phlebitis, varicose veins, pressure upon veins caused by tumors, 
the pregnant uterus and inflammatory products, and pressure caused by 
a dislocation or fractured bone, as well as organic disease of the heart 
and lungs and cirrhosis of the liver, afford familiar instances of the more 
common mechanical interferences with the venous circulation. The 
chronic or frequently recurring hypersemia in a part usually results in 
increased nutritive activity of the tissues and hyperplasia in the 
absence of infection. This effect of chronic hypersemia has been made 
use of in practice by producing the condition artificially in the treat- 
ment of tubercular affections accessible to this kind of treatment 
(Bier). Redness as a symptom of inflammation signifies an excess of 
blood in the part, and the terms used to indicate its existence are 
hypersemia and congestion, while complete arrest of the capillaiy cir- 
culation is expressed by the word stasis. Accurately speaking, hyper- 
semia should be used to designate that condition of the circulation 
where the part not only contains an increased amount of blood, but 
where an increased amount of blood flows to and returns from the part, 
—an exalted physiological process ; while the word congestion literally 
means only an accumulation of blood in a part, — a condition owing to 
some form of local or distant mechanical obstruction. The conditions 
giving rise to redness, hypersemia, congestion, and stasis should not be 



SYMPTOMS OF INFLAMMATION. 



91 



studied only from descriptions, but in order to be understood they 
should be seen. This can be readily done by producing artificially an 
inflammation in a transparent part of some lower animal, preferably 
the frog, and studying the circulation in the inflamed part step by 
step under the microscope. For this purpose experimenters have 
usualty selected the frog's web, mesentery, tongue, lung, and bladder, 
and the tadpole's tail. For general use the frog's web should be selected, 
as the preparations for this experiment are very simple. Inflammation 
is provoked by cauterizing the web with a needle heated to a red heat, 
or by applying with a small 
plug of cotton some power- 
ful irritant, as ammonia, 
tincture of cantharides, or 
croton-oil, or by touching 
the surface with a sharp 
stick of nitrate of silver. 
Hamilton gives the follow- 
ing directions for making 
the experiment: "Nothing 
more is necessary than a 
piece of tin or other soft 
metal, about 1J to 2 inches 
broad and about 6 to 8 
inches long, or, what is 
better, a thin piece of hard 
wood of the same dimen- 
sions. At the end where 
the web is to be stretched it 
should not be so broad. 
From the narrow end of 
this a V-shaped piece is cut 
out, over which the web 
is to be spread. The frog 
should first be curarized, as this does not interfere with the circulation, 
provided that the solution employed be not too strong. The ^W °f ll 
grain, in watery solution, injected under the skin, is sufficient. Chloral 
may be substituted. Caton recommends a solution of 4 grains to the 
drachm. As many minims should be injected subcutaneously as the 
frog is drachms in weight. The injection is made under the skin of 
the back with an ordinary hypodermic syringe. The animal is laid on 
the piece of metal or wood, and, the web being stretched over the cleft 
at the end, the toes are held by tying a piece of thin thread to them and 




Fig. 58.— Normal Circulation in Frog's Web. 
(Landerer.) 

A, artery ; B, vein ; C, capillaries. Vessels covered by a net-work 
of polygonal epithelial cells of web, in which pigmented cells are not 
represented. 



92 



PRINCIPLES OF SURGERY. 



fixing the ends into a fine slit cut in the metal or wood." The micro- 
scope is so arranged and adjusted that the field of observation will cor- 
respond to the point of irritation. A sufficiently high power is used so that 
the different corpuscular elements in the capillary stream can be readily 
seen and recognized. In order to witness the different stages of the 
inflammatory process it is necessary to continue the observation for 
hours. 

Any one of the irritants mentioned applied to the frog's web will 
produce in the capillaries over a limited area a series of changes which 

are always present in in- 
flammation, and a descrip- 
tion of them will repre- 
sent what takes place in 
capillaries the seat of in- 
flammatory processes of 
bacterial origin ; almost 
simultaneously with the 
application of the irri- 
tant a momentary con- 
traction of the vessel 
occurs, caused by the 
stimulation of the vaso- 
constrictor nerves, which 
is followed by dilatation, 
with increased velocity 
of the capillary current, 
— a true hyperemia. The 
bright-red color of the 
hypersemic part at this 
stage, according to Reck- 
linghausen, is due to in- 
crease in the rapidity of 
the blood-current, but, as 
the color of the blood indicates a diminished expenditure of oxygen 
and a smaller quantity of carbon in the blood, increased velocit}' 
alone would not explain this change. Diminished alkalescence in the 
inflamed tissues maj r reduce the amount of oxj'gen used, as is the case 
in glands during active secretion, where Claude Bernard showed that 
defective oxygenation is always present. At this stage the corpuscular 
elements circulate in their respective streams, and the whole picture is 
one of increased physiological activity. Dilatation of the vessels follows 
contraction so quickPy that it would be difficult to explain it as a para- 




Fig. 59.— Capillaries of Frog's Web in a State op 
Hyperemia soon after Application of Irri- 
tant. (Landerer.) 

A, artery ; B, vein ; C, capillaries. 



SYMPTOMS OF INFLAMMATION. 93 

lytic phenomenon. Its early outset and the rapidity with which it ap- 
pears would point to a neurotic cause, traceable to the action of ganglia 
in the vessel-wall. It has not yet been satisfactorily explained whether 
this early dilatation of the vessel is due to vasomotor paralysis or 
irritation of the vaso-dilators, but it is more probable that it is caused 
by the vaso-dilators, while, later, paralysis from overdistention occurs. 
Division of the sympathetic in the neck brings about increased vascu- 
larity, but no inflammation. The difference between dilatation of an 
inflamed vessel and the dilatation following division of the sympathetic 
consists in alteration of the capillary wall, in the former instance pro- 
duced by the action of the causes which induced the inflammation, while 
in the latter the dilatation is a purely nervous phenomenon, unattended 
by other pathological conditions of the vessel-wall. Disturbances of the 
circulation alone are not sufficient to bring about the local changes which 
are characteristic of inflammation ; if the velocity of the blood-current 
is greatly diminished by purely mechanical or nervous causes, mural 
implantation of the white corpuscles may take place, but emigration 
does not occur on account of the absence of the essential condition 
which gives rise to it, — alteration of the capillary wall. 

Dilatation is first noticed in the smallest arteries, afterward in the 
veins and capillaries, and keeps increasing from fifteen minutes to two 
hours. The vessels often enlarge to double their normal calibre. During 
the stage of dilatation many of the capillaries which were small or con- 
tained but little blood become visible, which greatly adds to the turgidity 
and redness of the inflamed part. As long as the acceleration of the 
capillary current continues, the different corpuscles move in their respec- 
tive currents. The white corpuscles that are mingled with the colored 
are washed along with the latter in the central stream without finding 
their way into the slower side-current which propels the leucocytes and 
the third corpuscles. The leucocytes in the peripheral stream appear 
more numerous, and skip along by more rapid rotatory movements. At 
this time the circulation has reached its greatest speed, and the tissues 
present every appearance of well-marked hyperaemia. In from fifteen 
minutes to two hours from the time the irritant was applied, intra-vascular 
changes are noticed which are calculated to impede the capillary current. 
The first link in the chain of local causes which obstruct the capillary 
circulation consists of a crowded condition of the vessels from a greater 
accumulation of the different corpuscles, which is soon followed by a 
greater separation of the leucocytes from the central current and their 
greater accumulation in the peripheral stream, where they often become 
arranged in heaps and little masses. This change is first observed in the 
small veins, and somewhat later, and to a lesser extent, in the smallest 



94 PRINCIPLES OF SURGERY. 

arteries. Separation of the blood-corpuscles is the necessary outcome 
of slowing of the stream from greater accumulation. In the peripheral 
zone of leucocytes the next source of obstruction is created. Some of 
the colorless corpuscles become momentarily attached to the capillary 
wall, when they are again detached by the force of the current, or are 
rolled away by another leucocyte. As the process advances it appears 
as though the viscosity of the leucocytes was increasing constantly, as 
more and more of them become adherent, while fewer are again detached. 
The lumen of the vessel is narrowed more and more by mural implanta- 
tion of the leucocytes. The small veins now assume an appearance as 
if the internal surface of their wall were paved with leucocytes, while in 
the capillaries a similar adhesion of the leucocytes to the wall is noticed. 
At this stage it often appears as though complete obstruction would 
occur every moment, the capillary stream becoming completely arrested 
for a moment, and the current may even move in an opposite direction, 
when the obstruction is again overcome and the current moves once more 
in the right direction. The smallest arteries exert themselves to the 
utmost to clear the way, and pulsations can be seen where in a normal 
condition they are absent. Hypersemia has now given way to congestion. 
An intra-vascular obstruction has given rise to accumulation of blood on 
the proximal side of the inflamed vessel. Increasing slowing of the 
current gives rise to greater accumulation of leucocytes, which become 
firmly adherent to the capillary wall, narrowing the vessel more and 
more until the space for the axial current becomes too small for the pass- 
age of the red corpuscles, when complete arrest of the circulation takes 
place. Congestion has resulted in stasis. As soon as complete stasis 
has taken place the colorless corpuscles become mixed with the red cor- 
puscles which are forced into the mass of the white, while by amoeboid 
movements the latter wander toward the centre of the vessel and mix 
freely with those which were moving in the central current. The most 
advanced stages of vascular disturbance are, of course, noticed first where 
the irritant was applied, so that when complete stasis has taken place in 
the centre a zone of congestion surrounds this, while more distant ves- 
sels still present every indication of active hyperemia. Redness is most 
marked where hypersemia is extant ; that is, in parts containing a maxi- 
mum amount of arterial blood. As soon as congestion sets in, the blood- 
corpuscles, red and white, do no longer pass through the vessel with the 
same rapidity and number, and the redness gives way to a bluish tinge, 
which becomes well marked and does not give way to pressure when 
complete stasis has occurred. The blood in the stagnated vessels, accord- 
ing to Paget, has little tendency to coagulate ; hence the possibility of 
resistutio ad integrum of the circulation after subsidence of the acute 



SYMPTOMS OF INFLAMMATION. 95 

symptoms. Complete stasis occurs first in such capillaries where the 
vis a tergo is greatly diminished by a circuitous route from an artery to 
a vein, and increases in the direction in which the blood-current is 
slowest. In warm-blooded animals the phenomena of inflammation do 
not differ materially from those observed in the frog's web, except as re- 
gards the presence and disposition of the third corpuscles. According 
to Eberth and Schimmelbusch, in warm-blooded animals the third cor- 
puscles in the normal capillary circulation move along with the colored 
corpuscles in the axial current, and hence they maintain that they must 
be of nearly the same specific gravity. A few of the leucocytes, mixed 
with the colored corpuscles and the third corpuscles, are found in the 
central stream, but the majority of them are propelled by the peripheral 
stream, which, according to those observers, is from ten to twenty times 
slower than the central or axial current. With the slowing of the stream 
from alteration of the capillary wall and subsequent intra-vascular condi- 
tions, separation of the corpuscles takes place in the same manner as 
has been described in the frog's web ; the leucocytes and third corpuscles 
leave the central stream and accumulate in the slower peripheral zone of 
the capillary stream, where they give rise to a greater degree of slowing of 
the column of blood by the formation of intra-vascular obstruction, which, 
if sufficient in degree, finally arrests the central current, thus causing 
stasis. The inflammatory process in warm-blooded animals can be studied 
advantageously in the artificially-inflamed omentum of young animals, 
especially the guinea-pig, as the omentum in these animals is exceedingly 
delicate and transparent. The animal is narcotized by injecting sub- 
cutaneously 3 grains of hydrate of chloral for a full-grown animal. As 
the animal, with the exception of the head, is to be kept immersed in a 
physiological solution of salt kept at a temperature of the body in a large 
vat with a glass bottom, it is wrapped in a sheet of gutta-percha tissue 
long enough to overlap the head, and made so as to inclose a funnel-like 
space through which it may breathe. An opening is made in the cover- 
ing at a point corresponding to the abdominal incision, through which 
the omentum is withdrawn. The object-glass of the microscope is im- 
mersed in the solution, and the omentum laid over a slide without fasten- 
ing it. The vat is made so that it will fit on to the stand of an ordinary 
microscope, so that the light can be readily adjusted. Two tubes, one 
to convey the salt solution into the vat and another to conduct it away, 
are attached at opposite sides. These can be connected with a vessel 
whose temperature is kept constant by means of a thermostat and Bunsen 
burner. 

(c) Swelling. — The primary swelling in inflammation is due to dila- 
tation of blood-vessels, and its degree will depend on the vascularitv of 



96 PRINCIPLES OF SURGERY. 

the part inflamed. The more numerous the blood-vessels, the greater the 
swelling from this cause. As the inflamed blood-vessels will often dilate 
within two hours to double their normal calibre, the primary swelling in 
vascular organs in a state of acute inflammation will come on quickly, 
and will give rise to a not inconsiderable enlargement of the inflamed 
part. If during this stage of inflammation the tissues are incised, 
haemorrhage is profuse, and the empt}ing of turgid blood-vessels by this 
means has a prompt effect in diminishing the swelling. Nancrede has 
shown by his investigations that local depletion, during the liyperaemic 
stage of inflammation, exercises a favorable influence in unloading the 
distended blood-vessels and in modifying the intensity of the subse- 
quent conditions in the inflamed tissues. It is also during this stage 
that the application of cold proves a beneficial resource in the treatment 
of acute inflammation, as under its effects the distended blood-vessels 
contract, and in consequence of the diminution of the vascularity of the 
inflamed part the primary inflammatory swelling is diminished. 

I. Inflammatory Exudation. — A moderate amount of swelling is 
present in all regenerative processes, as dilatation of the vessels neces- 
sarily precedes the increased physiological activity of the tissue, and the 
embryonal material required in the reparative process occupies a larger 
volume than the mature tissue it is intended to replace. Inflammation 
is characterized by the presence of a superabundance of cells. The cause 
which has produced the inflammation has, by its direct action upon the 
capillary wall, produced such alterations of its structure as to render it 
more porous, hence permeable to the passage of the inclosed cellular 
elements of the blood. The albuminous cement-substance which holds 
together the endothelial cells disintegrates at different points, and 
through these small defects, the stigmata and stomata, the blood-cor- 
puscles find their way through the capillar} 7 wall into the surrounding 
lymph and connective-tissue spaces. In acute inflammation the inflam- 
matory exudation consists principally in the extra-vascular accumulation 
of blood-corpuscles which have passed through the injured capillary 
wall. The rapidity with which the inflammatory exudation appears will 
depend on the intensity of alteration of the capillary wall and the speed 
with which the blood-corpuscles escape into the surrounding tissues. 
In chronic inflammation exudation takes place slowly , and the histological 
elements of the inflammator} 7 swelling are derived mostly from the fixed 
tissue-cells. 

Emigration of Leucocytes. — The passage of a leucocyte through a 
defect in the capillary wall is called emigration, — the wandering of such a 
cell from a place where it has a normal existence into a territory where, 
in a condition of health, it is seldom met with. After it has made its 



SYMPTOMS OF INFLAMMATION. 97 

escape from the capillary vessel it is called an emigration or wandering 
corpuscle. John Hunter came very near being the discoverer of emigra- 
tion of leucoc} 7 tes during his researches on inflammation. He incised 
the tunica vaginalis in animals, and inserted a tallow plug, which he 
removed after short intervals, and examined the fluid upon its surface 
under the microscope. He found in this fluid, a short time after the in- 
cision was made, round, white cells, which could have been nothing else 
but wandering leucocytes. 

The credit for having demonstrated the porosity of the capillary 
wall and the escape of the colorless corpuscles unquestionably belongs to 
Waller. This author observed emigration in the tongue of the frog as 
early as 1846, and strongly maintained that the inflammatory exudates 
were composed largely of leucocytes, in opposition to the blastema theory 
of formation of pus and other inflammatory products. 

In 1849 Addison clearly pointed out the relationship of the color- 
less corpuscles and the corpuscles lying around the vessel in inflamed 
parts, as becomes evident from the following sentences from his work on 
"Consumption and Scrofula:" "During inflammation — using the word 
in the general sense here indicated — there is more or less marked increase 
of the colorless elements and protoplasm in the part affected. At first 
— in the first stage — these elements adhere but slightly along the inner 
margin or boundary of the nutrient vessels, and are therefore still within 
the influence of the circulating current, belonging, as it were, at this 
period as much, or rather more, to the blood than to the fixed solid. 
Secondly — in the second stage — they are more firmly fixed in the walls 
of the vessels, and, therefore, now without the influence of the circu- 
lating current. Thirdly — in the third stage — new elements appear at the 
outer border of the vessels, where they add to the texture, form a new 
product, or are liberated as an excretion." 

Recklinghausen found wandering corpuscles in the vascular spaces 
of the cornea, but he believed that they were a product of tissue pro- 
liferation from the fixed corneal corpuscles. Our modern knowledge of 
emigration of leucocytes is founded almost exclusively upon the labors 
of Cohnheim. This observer demonstrated, in the }^ear 1861, by his 
own ingenious experiments, that the wandering corpuscles discovered by 
Recklinghausen in the vascular spaces of the cornea were leucocytes 
which had escaped from capillary vessels and had wandered into the 
cornea. He based his statements on the results of an experiment which 
could leave no room for discussion. He injected finety-divided pigment- 
material directly into the circulation of an animal, and somewhat later 
produced artificially a keratitis. In examining the cornea he found the 
vascular spaces nearest the margin of the cornea crowded with leuco- 



98 PRINCIPLES OF SURGERY. 

cytes loaded with pigment-granules. There could be only one conclu- 
sion, — that the leucocytes, which had become charged with pigment- 
granules in the general circulation, had passed through the capillary 
vessels at a point nearest the seat of irritation ; in other words, the 
capillary vessels which took part in the traumatic keratitis furnished 
the primary inflammatory exudation. A slight irritation of a frog's 
webb will only produce an active hyperemia, and in a short time the 
circulation returns to normal without any emigration of leucocytes 
having taken place. In such cases the irritant has been of such a 
nature or of such mild action as not to produce the necessary alteration 
of the capillary wall for mural implantation and emigration to take 
place. 

Zahn has shown that if the mesentery of an animal is exposed, but 
carefully protected against injury, emigration of leucocytes does not 
take place for seven or eight hours, while the remaining disturbances of 
the circulation indicate the existence of inflammation. If, however, the 
frog's web or tongue is cauterized with a sharp-pointed pencil of nitrate 
of silver the necessary conditions for an acute inflammation are created, 
and the minute eschar is soon surrounded by vessels showing the differ- 
ent stages of the inflammatory process, from active hyperemia to com- 
plete stasis. Emigration of leucoc3 T tes takes place most actively in 
capillaries partly obstructed by mural aggregation of these elements, and 
the process is arrested as soon as the circulation has come to a complete 
standstill. The following conditions must be present and are essential 
for emigration of leucocytes : 1. Alteration of capillary wall. 2. Mural 
implantation of leucoc}^tes. 3. Permeability of lumen of capillary vessel. 
4. Amoeboid movements of leucoc3<tes. 

1. Alteration of capillary wall has been repeatedly enumerated as 
the most important feature of inflammation, and without such a change 
the rapid escape of leucocytes as we find it in inflammation would be 
utterly impossible. The cause which has produced the inflammation 
produces such a degree of softening in the cement-substance as to enable 
its penetration by the leucocytes between the endothelial cells, or, as some 
of the authors claim, localized minute defects cause the formation of 
small openings through which the leucocytes escape. 

2. Mural implantation of leucocytes is an equallj T essential condition, 
as without it the leucocytes, which are at any rate larger in circumference 
than the supposed openings through which they escape, would be rolled 
over these minute defects by the sluggish peripheral stream, and emigra- 
tion would not take place. Increased adhesiveness or viscosit}' of the 
leucocytes is supposed to play an important part in the occurrence of 
mural implantation. According to Hering, mural fixation of the leuco- 



SYMPTOMS OF INFLAMMATION. 



99 



cytes is effected by fine projections, which are thrown out on their sur- 
face, and which insinuate themselves into the small crevices of the rough- 
ened intima. Mural implantation cannot take place as long as the capil- 
lary stream retains its normal velocity ; hence, slowing of the peripheral 
current is the first and most important cause. The slower the peripheral 
stream, the more readily does mural implantation occur, and the greater 
the tendency to aggregation of leucocytes along and near the capillary 
wall. The rapid transudation of the plasma of the blood through the 
defective capillary is undoubtedly another cause of impediment of prog- 
ress and final adhesion of leucocytes to the inner surface of the capil- 
lary vessel. Finally, mural fixation of leuco- 
cytes is effected by the changed condition of 
the protoplasm of the leucocytes and the inner 
surface of the capillary wall by the action of 
the essential cause which produced the inflam- 
mation. 

3. It has been shown that emigration of 
leucocytes is most active where the capillary 
circulation has become impeded, but not ar- 
rested, and that the process is arrested with the 
occurrence of complete stasis ; hence, it ap- 
pears that the intra-vascular pressure is one 
of the factors in this process. Hering and 
Schklarewsky maintained that the leucoc} 7 tes 
are entirely passive structures in their passage 
through the capillary wall, that they are forced 
through defects in the wall exclusively by the 
intra-vascular pressure. That emigration is not 
such a simple process is evident, as there would 
be in such case a larger representation of colored 
corpuscles in the inflammatory exudation. The 
blood-pressure assists in the extrusion of leuco- 
cytes that have penetrated the capillary wall, but, without changes in 
their form, would not be adequate to force them through the minute 
openings or the softened cement-substance. 

4. Leucocytes, in order to pass through an inflamed capillary wall, 
must possess amoeboid movements ; hence, only living leucocytes are 
capable of migration. 

After the leucocj^te has become implanted upon the inner surface 
of the capillary wall it penetrates the softened cement-substance by 
throwing out projections, or one of these projections insinuates itself 
into one of the minute foramina, and as the intra-mural portion increases 




Fig. 60.— Leucocyte Pass- 
ing through Capillary 
Wall. (Lander er.) 

A, leucocyte attached to capillary 
wall by delicate processes ; higher up 
it has penetrated the capillary wall by 
a large projection ; B, half of the leuco- 
cyte outside of the capillary wall drag- 
ging the balance after it. 



100 PRINCIPLES OF SURGERY. 

in size the balance of the leucocyte is drawn toward it ; this step is 
greatly aided by the blood-pressure, which pushes the intra-vascular por- 
tion in the direction of the growing projection, until by its own exertions, 
and aided by the vis a tergo, it has finished its journey through the capil- 
lary wall, and has reached the para-vascular lymph or connective-tissue 
spaces, where it constitutes the most important element of the inflam- 
matory exudation. In the inflamed capillaries of the frog's web, under 
the microscope, this process of emigration can be readily followed, and 
leucocytes can be seen in the same field in various stages of transit 
through the wall, and finally liberated in the para-vascular spaces. Fre- 
quently one leucocyte after another can be seen passing through the 
same place, — a fact which points strongly to the existence of well-defined 
circumscribed defects in the capillary wall. As the escaped leucocytes 
accumulate outside of the capillary vessels, some of them can be seen to 
change their location by the same forces which have been active in their 
passage through the vessel-wall, — amoeboid movements and stream of 
parenchyma fluid. 

Diapedesis. — This word was devised by Strieker to designate the 
passage of colored corpuscles through the inflamed vessel-wall. If there 
could be any doubt as to the existence of minute openings in the inflamed 
capillary wall in the consideration of emigration of leucocytes, this 
doubt must be effectually dispelled when the passage of colored corpuscles 
through the capillary wall can be demonstrated under the microscope. 
Experimental research and clinical observation have shown that when 
the inflammatory action is very intense red corpuscles form no inconsid- 
erable part of the inflammatory exudation. As the colored corpuscles 
possess only limited amoeboid movements, their passage through the capil- 
lary wall must be largely a passive process ; they are excluded through pre- 
formed openings or through an exceedingly soft cement-substance by the 
intra-vascular pressure. It is possible that they are forced through pas- 
sages made by the emigration corpuscles. It is well known that at 
first only leucocytes are found outside of the capillary vessels, that the 
colored corpuscles appear later, and that, while leucocytes also pass 
through the smallest veins, the colored corpuscles escape only through 
capillary vessels (Fig. 61, D). 

Arnold noticed that red corpuscles floating in the capillary stream, 
when they arrived opposite a stoma, were drawn toward the opening 
of the transudation stream. 

Diapedesis becomes a prominent feature where the inflammatory 
process is very acute, consequently where extensive alteration of the 
vessel-walls has taken place. In such instances the colored corpuscles 
are so numerous in the exudation as to impart to it a hemorrhagic 



SYMPTOMS OF INFLAMMATION. 



101 



appearance. An abundant escape of colored corpuscles in inflammation 
is technically called rhexis. The third corpuscles are extruded through 
the inflamed capillary wall in the same passive way as the colored 
corpuscles. 

The primary inflammatory exudation consists of the corpuscular 
elements of the blood which escape through the porous capillary wall, 
the products of their disintegration, and blood-plasma. The latter will 
be again referred to under the head of Transudation. The presence of 
the solid constituents of the blood differentiates the inflammatory exuda- 
tion from an ordinary hydropic or cedematous swelling. The question 




Fig. 61.— Inflammation of Frog's Web at Stage where Capillary Stream 
is Impeded by Commencing Emigration. (Landerer.) 

A, small artery ; B, small vein ; C, capillaries ; D, red corpuscles which have escaped from capillary by diapedesii. 

arises, What becomes of the corpuscular elements after they have 
left the general circulation? The most favorable termination of the 
inflammatory process consists in the preservation of the vitality of 
the cellular elements outside of the blood-vessels and their return 
into the general circulation by a process which is called immigra- 
tion. This probably seldom, if ever, takes place in the case of the 
colored and third corpuscles, which undergo molecular disintegra- 
tion, and the glandular detritus is removed by absorption. The 
leucocytes which have retained their vitality can return into the 
circulation either by re-entering the capillaries which they have left, 



102 PRINCIPLES OF SURGERY. 

after the acute symptoms have subsided and the capillaries have been 
cleared of the mural thrombi, or by a more indirect route through the 
lymphatic vessels. The latter route is probably the most frequent. If 
the blood-corpuscles contain the microbic cause of the inflammation in 
sufficient quantit} 7 and intensity to destroy their protoplasm, they fur- 
nish the necessaiy nutrient medium for the growth and development of 
the microbe outside of the vessel-wall, thus bringing it in direct contact 
with the para-vascular tissues, which then become the seat of infection. 
In such instances the cellular elements of the primary inflammatory exu- 
dation are dead tissue, and act or are disposed of as such. In acute 
suppurative inflammation the leucocytes which have escaped are con- 
verted into pus-corpuscles. The emigration corpuscle under no circum- 
stances assumes a tissue-producing function. When inflammatory proc- 
esses result in the formation of new tissue, this function is performed by 
fixed tissue-cells which have been stimulated to a state of activity by 
the increased nutritive conditions incident to some form of inflamma- 
tion. The albumen, which is alwa} T s present in considerable quantity in 
every inflammatory exudation, furnishes an additional nutrient supply, 
and thus assists the process of cell proliferation ; this is especially the 
case with the globulins. The filtrate which percolates through the in- 
flamed capillary wall contains coagulable substances, which, in hydropic 
fluids, are less abundant. The emigration corpuscles, which disintegrate 
soon after they have left the capillary vessels, furnish fibrin ferment. 
Fibrin production in the tissues is suspended as soon as the product of 
emigration has become copious. The third corpuscles furnish another 
source of fibrin production. In suppurative inflammation fibrin forma- 
tion does not take place. Where no fibrin forms in the exudation, the 
supposition lies near that the fibrin-producers are taken up by the cells, 
or that the fibrin which had already been produced is liquefied and 
assimilated by them. If the inflamed vessels are surrounded onty by 
a few leucocytes, the latter are destroyed and liberate fibrin ferment ; 
if abundant, they are more resistant and destroy albuminous substances. 
Weigert asserted that cell necrosis resulted in the formation of fibrin, as 
the dead cells furnish the fibrin ferment. That fibrin production does 
not always attend inflammation can onty be explained by the supposition 
that the fibrin-producers are assimilated as soon as thej' have left the 
blood-channels. If the cells which furnish the fibrin come in contact 
with necrotic tissue, such an assimilation is prevented and fibrin is 
formed. Fibrin production, however, may take place without cell necro- 
sis, as is the case upon inflamed serous surfaces. Its occurrence in this 
particular locality can only be explained by the absence of assimilation 
of the cells which yield the fibrin ferment. The cellular constituents 



SYMPTOMS OF INFLAMMATION. 103 

and fibrin of the inflammatory exudation impart to it one of its charac- 
teristic clinical features, — a sense of firmness, — which is well marked in 
proportion to the predominance of these over the fluid portion. 

2. Inflammatory Transudation. — The liquid portion of the blood which 
escapes through the damaged wail of inflamed capillary vessels is called 
inflammatory transudation. The same causes which are necessary to 
extrude the non-amoeboid corpuscular elements of the blood constitute 
also the conditions which enable a part of the blood-plasma to leave the 
capillary stream. Increased porosity of the capillary wall is the most 
important of them. As soon as the capillary wall has become abnor- 
mally permeable the blood-pressure forces the fluid through the minute 
pores into the surrounding connective tissue, or, if the inflammation is 
located in a mucous or serous membrane, upon the surface. In deep- 
seated inflammation the transuded fluid freely percolates through the 
connective-tissue spaces, and gives rise to one of the well-known symp- 
toms of inflammation, — the inflammatory oedema. The transudation is 
always more widely diffused than the exudation. Recent bacteriological 
researches have shown that, while in the tissues, at the seat of exuda- 
tion, the presence of the microbic cause of the inflammation can be 
readily demonstrated by microscopical examination and cultivation ex- 
periments, the oedema fluid some distance from them was found free from 
microorganisms. The escape of blood-plasma in inflammation is a proc- 
ess which resembles percolation through a porous membrane. As the 
blood-plasma contains fibrinogen-and fibrino-plastic material, its presence 
in the tissues or upon inflamed serous or mucous membranes is impor- 
tant in the production of fibrin. In some instances the inflammatory 
product is greatly changed by the presence of a copious transudation, 
and the inflamed part then presents more the appearance of oedema than 
inflammation. This is well shown by the two clinical varieties of anthrax. 
The expression serous inflammation is used to indicate the predominance 
of transudation over exudation in some forms of inflammation. The 
liquid transudate predominates over the exudate in some forms of sup- 
purative inflammation (purulent oedema of Pirogoff), also when the 
circulation is feeble, as in the aged and in anaemic individuals. The 
addition of mucus alters the character of an exudation or a transudation, 
as maybe seen when a mucous membrane is the seat of inflammation. 
Serous transudation often precedes mucous exudation, as in cases of 
acute catarrhal inflammation of the nasal passages. After the acute 
symptoms of inflammation have subsided and the capillary circulation 
has been restored, the transuded fluid is absorbed, and with its absorp- 
tion the inflammatory oedema disappears. In suppurative inflammation 
the transudation becomes the pus-serum. 



104 PRINCIPLES OF SURGERY. 

(d) Heat. — Increase of temperature of the inflamed part is the result 
of increased afflux of blood and the accompanying augmentation of 
physiological processes. Cohnheim showed experimentally that inflam- 
mation, without an increased blood-supply, does not give rise to an 
increase of temperature. John Hunter was already aware that the 
temperature at the seat of inflammation is never in excess of the tem- 
perature of the blood. Heat is both a subjective and objective symptom. 
In acute inflammation of the skin, or a mucous membrane,, the patient 
often complains of a distressing burning or scalding sensation, which is 
often effectually relieved by cold applications. The surface thermometer 
is sometimes an important instrument in settling a differential diagnosis 
between a deep-seated chronic inflammation and a malignant tumor. 
Diminution of temperature may indicate either a favorable change or 
complete arrest of circulation in the inflamed part, in the first instance 
showing that resolution is in progress, in the latter announcing the 
speedy occurrence of gangrene. 

(e) Disturbance of Function. — As inflammation, wherever it occurs, 
consists essentially of increased nutritive changes in the tissues, result- 
ing in consequence of a more abundant blood-supply and an exaggerated 
vegetative capacity of the cells, it may lead to at least a temporary in- 
crease of function. This is always the case in inflammation of mucous 
membranes, where, as one of the prominent clinical features, we observe 
an increased secretion of mucus usually preceded and accompanied by 
a more or less profuse transudation. Parenchymatous inflammation in 
glands usually produces sudden diminution and often complete suppres- 
sion of secretion. Acute suppurative osteomyelitis is attended by almost 
complete suspension of all the functions of the affected limb. Myositis 
arrests the contractility of the muscles affected. The pain caused by 
an inflammation may interfere with the functions of adjacent organs, as 
may be seen in the fixed chest-wall in cases of acute pleuritis, and in fixa- 
tion of the abdominal walls, with diminished or suspended respiratory 
movements of the diaphragm, in cases of peritonitis. The accumulation 
of inflammatory products may prove a serious obstacle to important 
functions, and often constitutes a direct cause of death, as in cases of 
intra-cranial inflammation, where death is more frequently caused by com- 
pression of the brain than destruction of the contents of the cranial cavity ; 
and the accumulation of serum or pus in the pleural cavity or pericardium, 
where a fatal termination can often be traced to mechanical causes from 
the presence of a copious effusion. Diminution of function often affords 
the earliest indication of the existence of a deep-seated chronic inflam- 
mation, as is evident from the slight limp which ushers in a coxitis or 
the imperfect flexion and extension in chronic inflammation of joints 
other than the hip-joint. 



CHAPTER IV. 

Inflammation (continued). 

MODIFICATION OF INFLAMMATION BY THE ANATOMICAL STRUCTURE 
AND LOCATION OF THE INFLAMED TISSUE. 

The clinical course and pathological conditions of inflammatory 
processes are materially modified not only by the primary cause, but 
also by the anatomical structure and location of the inflamed tissues. 
Inflammation of serous or mucous surfaces has a tendency to spread in 
a peripheral direction, and, as a rule, remains superficial, and the exuda- 
tion and transudation are poured out in the direction offering the least 
resistance; that is, upon the free surface. In tissues that are dense and 
unjielding the swelling, for physical reasons, is limited, and the inflam- 
matory products give rise to tension, which may arrest the circulation 
completely and cause necrosis, as is the case in acute suppurative osteo- 
myelitis. When the area of inflammation is supplied with an abundance 
of connective tissue the swelling often attains enormous dimensions in 
a short time, as may be seen in ever} 7 case of phlegmonous inflammation 
of the deep-seated connective tissue of the extremities, neck, chest, and 
abdomen. Acute inflammation of organs that are exceedingly vascular 
gives rise to an early and abundant exudation, as can be demonstrated in 
every case of croupous pneumonia and acute nephritis. Inflammation 
of non-vascular tissue is accompanied by the formation of new blood- 
vessels, which grow in the direction of the seat of inflammation from the 
nearest vascular district. Some tissues are more disposed to inflamma- 
tion than others ; thus, the connective tissue is more frequently the seat 
of acute inflammation than muscles, and the medullary tissue than the 
bone-substance proper, and most causes which give rise to chronic 
inflammation are known to select certain organs and tissues in preference 
to others. 

PARENCHYMATOUS INFLAMMATION. 

In the study of the cardinal s}nnptoms of inflammation special 
attention was given to the part taken in the inflammatory process by the 
capillary vessels and the blood-corpuscles. Alteration of the capillary 
wall was alluded to as the most important pathological condition, as 

(105) 



106 PRINCIPLES OF SURGERY. 

upon it depends the emigration of the corpuscular elements of the blood 
and the occurrence of the inflammatory transudation, which together 
constitute the primary inflammatory swelling. Incidentally it was stated 
that as soon as the cause which gave rise to the inflammation is brought 
in direct contact with the fixed tissue-cells, these take part in the in- 
flammatory process and contribute their share to the inflammatory exu- 
dation. Inflammation is said to be parenclrymatous when the parenchyma 
of an organ is the primary seat of inflammatory changes, as when the 
secreting structures of a gland are implicated from the beginning. In 
all such instances the blood-vessels which furnish the vascular supply 
have undergone the characteristic changes which have been described, 
and with few exceptions the microbes have been conveyed to the 
parenchyma through them. The cloudy swelling of parenchyma cells is 
either an evidence of the existence of degenerative changes, or it denotes 
the beginning of coagulation necrosis from the specific effect of patho- 
genic microbes upon their protoplasm. A cloudy appearance of cells is 
one of the first manifestations of the presence of a parenchymatous in- 
flammation. Lesion of connective tissue or parenchyma cells is next to 
alteration of the capillary wall, and emigration of the blood-corpuscles the 
most important pathological condition of inflammation, and, as far as the 
ultimate result is concerned, the most important, as extensive destruction 
of parenchyma cells will result in suspension of function, and death of 
the organ affected is one of vital importance. As soon as the fixed tissue- 
cells outside of the vessel-wall have become implicated their physiological 
resistance is diminished, — a condition which cannot fail in aggravating the 
existing vascular disturbances. Landerer maintains that the normal 
elasticity of the tissues surrounding the capillary vessels is an essential 
factor in preserving the equilibrium between the intra-vascular pressure 
and the surrounding tissues in a normal condition of the circulation. 
This mechanical theory of inflammation is founded upon the supposition 
that this normal elasticity of the para-vascular tissues is diminished by 
the causes which give rise to inflammation, and that when this has 
occurred the capillary walls have lost their outer support, in consequence 
of which they become dilated, and hyperemia, slowing of blood-current, 
emigration, and transudation follow as the result of purely mechanical 
causes. Ingenious as tjiis theory may appear, it cannot explain the 
complicated processes which characterize inflammation. The train of 
pathological conditions which attend inflammation must be regarded as 
effects of a common microbic cause upon the capillary wall, their con- 
tents, and the fixed tissue-cells outside of the capillary vessels. In 
parenchymatous inflammation the cause has reached the parenchyma 
cells, either directly, as when microbes are brought in contact with a 



INTERSTITIAL INFLAMMATION. 107 

mucous surface, become attached to and penetrate the parenchyma cells, 
multiply in their interior, and, later, reach the connective tissue and 
blood-vessels, or, what is more common, the microbes reach the paren- 
chyma through the circulation. In both instances the capillary vessels 
and the connective tissues between them and the parenchyma cells take 
an active part in the inflammatory process. The microbes may be 
present in such great number or may possess such intensely virulent 
properties as to destro} 7 the parenchyma cells, as is the case in diphtheritic 
inflammation of mucous membranes. When less intense in their action 
the parenchyma cells proliferate, and the embryonal cells, being less re- 
sistant, succumb later, as when suppuration occurs in the parenchyma 
of an organ, or they remain indefinitely in their embryonal state, as can 
be readily verified by examining the different forms of chronic inflam- 
matory swellings, — the so-called granulomata. 

INTERSTITIAL INFLAMMATION. 

In this form of inflammation the connective tissue is the seat of cell 
emigration and tissue proliferation. Many of the microbes select the 
connective-tissue spaces; they locate and multiply here, and the inflam- 
matory product is composed almost exclusively of emigration corpuscles 
and embryonal connective-tissue cells. Tubercle and gummata present 
such a histological structure. Phlegmonous inflammation represents the 
acute form of connective-tissue inflammation. If the connective tissue 
of an organ becomes the seat of an inflammatory hyperplasia the paren- 
chyma suffers, either in consequence of pressure or, later, from cicatricial 
contraction and the inevitable diminution of blood-supply incident to 
this condition. Parenchymatous inflammation of an organ is preceded 
or followed by interstitial inflammation, and a primarily interstitial in- 
flammation sooner or later involves the surrounding tissue by direct 
extension of the inflammatory process, or indirectly by the mechanical 
causes ; hence, as a rule, it is anatomically and even etiologically not 
always possible to differentiate between these two forms of inflammation, 
nor is such a distinction of much practical importance. 

HEMORRHAGIC INFLAMMATION. 

A few colored corpuscles escape through the capillary wall in almost 
every case of acute inflammation, but their presence in the exudation 
can only be determined by the use of the microscope. When they are 
present in sufficient number to impart to the exudation a blood} 7 tinge, 
we speak of a haemorrhagic exudation or transudation. A hemorrhagic 
transudation into the pleural, pericardial, or peritoneal cavit} r usually 
indicates the existence of a tubercular or malignant disease of the 



108 PRINCIPLES OF SURGERY. 

respective serous membranes. In cases of acute inflammation with hsem- 
orrhagic exudation, the quantity of the effused blood will be a sign by 
which we can at least approximately estimate the extent of alteration of 
the capillary wall. Rhexis can only take place when the capillary wall 
at some point has been completely broken down and an opening of con- 
siderable size has formed through which a small stream from the axial 
current can escape. Aside of the nature and intensity of the primary 
cause of the inflammation, hsemorrhagic inflammation is more likely to be 
met with in persons debilitated from other diseases, in the aged, and in 
patients suffering from diseases which obstruct the circulation, such as 
valvular disease of the heart, cirrhosis of the liver, emphysema of the 
lungs, and chronic affections of the kidney. The presence of blood in a 
transudation or exudation is always a grave sign, and as such should 
always be taken into careful consideration in rendering a prognosis. 

SUPPURATIVE INFLAMMATION. 

In suppurative inflammation at least a part of the exudation is 
transformed into pus. Transformation of the cellular portion of the 
exudation, the leucocytes and embryonal cells, into pus-corpuscles is due 
to the destructive effect upon their protoplasm of the pus-microbes and 
their ptomaines, while the transudate becomes the pus-serum. Suppu- 
rative inflammation occurs either as the result of a primary or secondary 
infection with pus-microbes. In primary infection with pus-microbes 
the leucocytes most remote from the blood-vessels, and which have been 
exposed longest to the specific action of the pus-microbes and their 
ptomaines, are converted first into pus-corpuscles, while the fixed tissue- 
cells are first transformed into embryonal cells before the same cause, by 
destruction of their protoplasm, changes them into similar structures. In 
suppurative inflammation due to secondary infection, the pus-microbes 
act upon embryonal cells which owe their origin to an antecedent infec- 
tion with another microbe of milder pathogenic qualities, as can be seen 
when tubercular granulations or a gumma undergo suppuration. Sup- 
purative inflammation, in all of its aspects, will be fully considered in the 
chapter on Suppuration. 

INFLAMMATION OF SEROUS MEMBRANES. 
Inflammation of the serous membranes has been called exudative, 
adhesive, suppurative, or serous, according to the character of the in- 
flammatory product. In most inflammatory affections of the serous 
membranes the surface becomes covered with a copious exudation, which 
is composed of leucocytes, fibrin, and the products of tissue proliferation 
of the endothelial and connective-tissue cell. The leucoc}^tes and third 



INFLAMMATION OF SEROUS MEMBRANES. 



109 



corpuscles are rapidly destroyed as they reach the surface, and the fibrin 
ferment and fibrino-plastic material which are liberated form, on com- 
bining with the fibrinogen of the blood-plasma, fibrin. The inflamed 
membrane is often covered by a thick layer of fibrin, which is firmly 
adherent to the surface by means of new blood-vessels and granulation 
tissue which have grown into it. The endothelial cells take an active 




Fig. 62.— Germinating Endothelium, Omentum of Young Dog. Acute Peritonitis. 

Silver-staining, X 350. {Hamilton.) 

A, natural endothelium covering wall of a mesh ; B, D, endothelial cells beginning to germinate ; C, a chain 
of germinating cells extending across a fenestra; E, mass of germinating endothelial cells. 

part in the inflammation, and in case the new product from this source 
is converted into connective tissue a permanent adhesion forms. In 
some instances the endothelial cells are destroyed and desquamation 
takes place, which leaves the subjacent connective tissue exposed. In 
such cases the superficial dilated capillaries have lost an important sup- 
port, and transudation takes place freely. D. J. Hamilton has studied 



110 



PRINCIPLES OF SURGERY. 



the histological changes which occur in periostitis by producing this 
disease artificially in young dogs. Besides desquamation, he has seen 
the endothelial cells multiply by division of the nucleus. 

The new cells resemble the ordinary granulation or embryonal cells. 
The connective tissue between the endothelial lining and the blood-vessels 




Fig. 63.— Omentum of Young Dog, Experimentally Inflamed. X 450. (Hamilton.) 

A, pyriform cell, probably of endothelial origin, sprouting from wall of a fenestra (S) of the membrane ; 
C, capillary, surrounded by extravasated leucocytes ; V, small vein, in similar condition. 

undergoes tissue proliferation, and the new cells reach the surface and 
mingle with those derived from the endothelial lining, so that the inflamed 
surface becomes covered with a layer of granulation tissue. The granu- 
lations, accompanied by dilated or new blood-vessels, penetrate into the 
fibrinous exudation, which is removed in the same manner as a thrombus 



INFLAMMATION OF SEROUS MEMBRANES. 



Ill 



in a blood-vessel undergoing obliteration. Permanent adhesions and 
obliteration of serous cavities are affected by the granulation tissue, 
which removes the inflammatory exudation and establishes an organic 
union between opposing inflamed membranes. If the fixed tissue-cells 
do not participate actively in the inflammatory process, the exudation 
becomes absorbed in the course of time, and the endothelial lining is 
repaired; thus the temporary adhesions are removed, and the normal 




Fig. 64.— Acute Pleurisy. X 300. (Hamilton.) 

A, A, net-work of fibrin ; B, an effused leucocyte ; C, laminae of fibrin lying adjacent to the 
pleura (F) ; D, small round cells effused into the pleura ; E, distended blood-vessel of the superficial 
layer of pleura. 

relations existing between the serous membrane and inclosea viscera are 
restored. The blending of the corpuscular elements of the inflammatory 
exudation of a serous membrane with the product of tissue proliferation 
of the endothelial cells is well shown in Fig. 63. 

The pathological anatomy of acute inflammation of a serous mem- 
brane at an early stage is well represented in Fig. 64. 

The scarcity of leucocytes in the fibrin in the specimen represented 
by this illustration was undoubtedly due to their rapid destruction as 



112 PRINCIPLES OF SURGERY. 

soon as the}' reached the surface, which resulted in the formation of a 
copious deposit of fibrin. The round cells in the subpleural connective 
tissue are effused leucocj^tes. Sufficient time does not seem to have 
elapsed for any marked changes to have occurred in the fixed tissue-cells. 
In suppurative inflammation of a serous membrane, if life is sufficiently 
prolonged, the leucoc} T tes and embryonal cells are transformed into pus- 
corpuscles, and in this manner emp3'ema, pyocardium, and purulent 
peritonitis are produced. The introduction of pus-microbes in sufficient 
quantity into the abdominal cavity, the power of absorption of which 
has been reduced b}^ an antecedent affection or an accompanying trauma, 
will produce such a rapidly fatal peritonitis that the peritoneum, on post- 
mortem examination, will show little, if any, macroscopical lesions. 
Death in such cases results from acute septic infection. When life is pro- 
longed for several days, the post-mortem reveals all the evidences of a 
fibrino-plastic peritonitis ; that is, numerous adhesions between the 
intestines and the parietal peritoneum and among the intestinal loops. 
In purulent peritonitis the exudation often breaks down as the leuco- 
cytes contained in it are converted into pus-corpuscles. Tubercular 
peritonitis is usually attended by a copious exudation, which limits the 
process and encapsulates the serous transudation. If, in an inflamma- 
tion of a serous membrane, the transudation predominates over the 
exudation, the character of the process is indicated clinically by a 
subacute or chronic course and the absence of severe sj^mptoms. Hydro- 
thorax often develops insidiously, and perhaps the first subjective 
symptom is difficulty of breathing. Tubercular peritonitis with copious 
circumscribed effusion has been frequently mistaken for ovarian cyst, 
not only because the swelling closely resembles a unilocular ovarian 
cyst, but also from the absence of any of the usual local symptoms which 
attend the usual forms of fibrino-plastic peritonitis. It appears that the 
causes which give rise to this form of inflammation of serous membranes 
do not act with sufficient intensity on the capillary wall and the para- vas- 
cular tissues to provoke a copious exudation and active tissue prolifera- 
tion, but create conditions which permit a copious transudation to take 
place. It has been recently a much-discussed question whether or not 
all cases of serous effusion into the chest are of tubercular origin. The 
fact remains that mai^r cases of subacute and chronic pleurisy die subse* 
quently from tuberculosis, and the natural conclusion would be that the 
disease was primarily caused by a localized tubercular focus, which, at 
the time, could not be detected. It is evident that the causes which 
produce serous transudation do so not only bj^ producing changes in the 
capillary wall which permit free transudation, but also b}' bringing about 
alterations which diminish or complete^ suspend the power of absorp- 



INFLAMMATION OF MUCOUS MEMBRANES. 113 

tion ; hence, not only the occurrence of transudation, but accumulation 
of the liquid effused. The presence of blood in the transudation is 
usually an indication of the presence of tuberculosis, carcinoma, or 
sarcoma. 

INFLAMMATION OF MUCOUS MEMBRANES. 

Inflammation of a mucous membrane represents another variety of 
surface inflammation which is greatly modified by the anatomical 
character of the tissue the seat of the inflammatory process. We have 
seen that inflammation of serous membranes presents as its most charac- 
teristic pathological feature a plastic exudation on its surface, composed 
of the exuded blood-corpuscles and the products of their disintegration, 
which are firmly attached to the endothelial lining, which in part has 
been destroyed and detached by desquamation, while the cells which 
have retained their vitality proliferate new tissue, which mingles with 
and ultimately removes the exudation. The epithelial cells which line 
mucous membranes when in a state of inflammation are stimulated to 
increased activity, and consequently secrete an increased quantity of 
mucus, which is the characteristic pathological and clinical feature of 

I. CATARRHAL INFLAMMATION. 

Inflammation of a muQous membrane is called catarrhal as long as 
the product consists of an increased secretion of mucus. If a part of 
the mucous lining is destroyed and the discharge becomes a mixture of 
pus and mucus, it is no longer proper to call it a catarrhal inflammation, 
as the pus-microbes have wrought changes that bring the process within 
the legitimate sphere of suppurative inflammation. Catarrhal inflamma- 
tion produces a thickening of the mucous membrane by infiltration of 
the submucous tissue, which, if copious, may subsequently give rise to 
cicatricial contraction, and, if the inflammation is located in a tubular 
organ, to the formation of strictures. According to Virchow, a catarrhal 
inflammation may lead to the formation of superficial ulcers, — the so- 
called catarrhal ulcers. 

II. SUPPURATIVE INFLAMMATION. 

In this form of inflammation of a mucous membrane, the leucocytes 
which are extruded upon its surface, as well as the embryonal cells, are 
destroyed by the pus-microbes and are converted into pus-corpuscles, 
which, when mixed with the mucus secreted by the cells which have 
retained their physiological function, form the muco-purulent discharge. 
Most of the ulcers which form upon mucous surfaces result from circum- 
scribed necrosis or suppurative inflammation. A catarrhal inflammation 
very frequently precedes the suppurative form, and a circumscribed sup- 



114 PRINCIPLES OF SURGERY. 

pu rating area is usually surrounded by a zone of catarrhal inflammation. 
Cicatricial obliteration of a tubular organ can only take place after ex- 
tensive defects of its mucous lining from necrotic, ulcerative, or trau- 
matic causes. Limited defects are repaired by regeneration of the epi- 
thelial cells, either from the margins of the defect or from remnants of 
glands. The most frequent causes of ulceration in the intestinal canal 
are dysentery, typhoid fever, and tuberculosis. Ulcers which result from 
the sudden obliteration of a small blood-vessel bj T thrombosis or embolism 
are met with after extensive burns in the upper portion of the small in- 
testine and in the stomach in chlorotic females. A strange form of 
perforative enteritis has recently been described by Mikulicz. A similar 
case was operated on in the Zurich Klinik, and a careful description of 
the pathological conditions found at the necropsy has been given by 
Klebs. He found multiple perforations in a circumscribed portion of 
the jejunum, and only a few of them had been found and closed by the 
surgeon who performed the operation. The perforations on the peri- 
toneal side were covered by a plastic exudation. The lumen of the 
intestine corresponding to the affected portion was considerably enlarged. 
Mucous membrane not much changed in appearance, but, on close inspec- 
tion, a number of small defects, partly hidden under the folds, were de- 
tected, and were found to correspond with the covered defects on the 
outer surface. On microscopical examination, it was found that the villi 
and mucous membrane were softened and denuded of the epithelial lining 
and infiltrated with cells over a considerable distance beyond the per- 
forations. The most marked changes were found in the submucous tissue, 
which was also much softened, and the scanty intercellular substance 
was found traversed by wide spaces in which were found numerous large 
cells with large oval nuclei. Besides these enlarged parenchyma cells, 
and in their vicinity, leucocytes which had undergone fragmentation 
were found. As the capillary vessels were much dilated and in a con- 
dition of inflammation, Klebs looks upon the process as a hyperplastic 
parenchymatous enteritis. As the leucocj'tes found in the tissues pre- 
sented all the evidences of fragmentation, there can be but little doubt 
that this rare form of enteritis presents only another variety of sup- 
purative inflammation of the mucous membrane of the intestine. 

III. CROUPOUS INFLAMMATION". 

When inflammation of a mucous membrane is attended by the 
formation of a fibrinous exudation or false membrane upon its surface, 
it is called croupous. The formation of a fibrinous exudation upon a 
serous surface, we have found, is always associated with a more or less 
extensive destruction and desquamation of endothelial cells, and a simi- 



INFLAMMATION OF NON-VASCULAR TISSUE. 115 

lar superficial change takes place in croupous inflammation. Weigert 
states that unless the epithelial surface of a mucous membrane be 
broken the inflammatory exudation from it will not coagulate. As 
croupous inflammation of a mucous membrane is always produced by 
direct infection, it is probable that the microorganisms destroy some 
of the epithelial cells ; and as the inflammatory process penetrates deeper 
into the tissue, the exudation and transudation coming in contact with 
dead tissue on the surface, fibrin is deposited, and, becoming entangled 
with the cellular debris, it becomes adherent to the partially-abraded 
and uneven surface. The fibrin is arranged in layers in the form of a 
coarse net-work, in the meshes of which is a finer reticulum of the same, 
with leucocytes and embryonal cells thrown off from the surface. Some 
membranes contain numerous leucocytes, while in others they are de- 
stroyed in the process of coagulation. Separation of a false membrane 
takes place either by the mucus secreted by intact cells underneath it, or, 
if the mucous lining has been completely destroyed, by suppuration and 
granulation. It has been claimed that, pathologically, a croupous mem- 
brane differs from a diphtheritic exudation in that in the former the 
lining of the mucous membrane is found intact after stripping it off, 
while in a diphtheritic inflammation there is always found a loss of sur- 
face substance after removing the membrane. Upon this more apparent 
than real anatomical difference the discussion on the non-identity of 
croupous and diphtheritic inflammation rests. As superficial coagula- 
tion necrosis is present in all cases of croupous inflammation, and if this 
process is etiologically different from diphtheritic inflammation, the 
pathological conditions are different only in degree and not in kind. 
False membranes, wherever they may form upon a mucous or serous sur- 
face, serve as nutrient media for microorganisms, and the underlying 
surface is subjected to the risks of recurring infection from them as long 
as they remain. 

DIPHTHERITIC INFLAMMATION. 

Diphtheritic inflammation is caused by the Klebs-Loffler bacillus. 
As a primary disease it affects most frequently the upper part of the 
respiratory tract. Extensive destruction of the mucous membrane 
underneath the exudation is a constant occurrence. Diphtheritic in- 
flammation is frequently complicated by secondary infection with pus- 
microbes and saprophytes, — a condition which greatly aggravates the 
local conditions and increases the danger to life. 

INFLAMMATION OF NON-VASCULAR TISSUE. 

The importance of blood-vessels in inflammation can be best shown 
by a study of the pathological conditions in inflammation of non-vascular 



116 PRINCIPLES OF SURGERY. 

tissue. The part taken by the blood-vessels and the fixed tissue-cells in 
the inflammatory process can be most satisfactorily demonstrated in 
non-vascular organs. 

Cornea. — Cohnheim first demonstrated emigration of the colorless 
blood-corpuscles in artificially-produced keratitis. He cauterized the 
cornea in animals, and then observed cell infiltration from its margins at 
a point corresponding to the nearest vascular supply. For the purpose 
of showing that the cells were not products of the fixed tissue- cells he 
injected, a few days before the cauterization, finely-divided cinnabar into 
the circulation, and found that the leucocytes, as they escaped from the 
capillary vessels, contained granules of the pigment which he had in- 
jected. The leucocytes were seen to wander through the vascular spaces 
of the cornea toward the seat of cauterization. As he could observe no 
changes in the fixed corneal corpuscles at the seat of cauterization, he 
maintained that the inflammatory product was derived exclusively from 
the blood, and that its escape from the blood-stream depended on altera- 
tion of the capillary wall. He regarded the dilatation of blood-vessels, 
which occurs soon after the application of the irritant, as a result of 
reflex action, and attempted to prove, by specimens of keratitis stained 
with chloride of gold, that the fixed tissue-cells remained unaffected by 
the inflammation. Strieker maintained the opposite view, and proved, 
in silver-stained specimens, that the corneal corpuscles had undergone 
changes which indicated that they performed an active part in the in- 
flammation. Recklinghausen resorted to a very ingenious experiment 
to establish his theory regarding the origin of the wandering cells in the 
vascular spaces of the cornea. He cauterized the cornea of a frog, 
excised it immediately, and kept it under conditions favorable to cell 
vegetation, and found, later, wandering cells in the vascular spaces, the 
origin of which he traced to tissue proliferation of the corneal corpuscles 
after excision; but even his assistant, F. A. Hoffmann, expressed the 
opinion that the cells might have been leucocytes which had entered the 
vascular spaces before the cornea was excised. It is more than doubtful 
that tissue proliferation would take place in an excised cornea, even 
under the most favorable physical conditions. There can be no doubt 
whatever that the primary exudation in traumatic keratitis, as in all 
other forms of acute inflammation, takes place from inflamed capillary 
vessels, as Cohnheim has demonstrated so beautifully ; but this constitutes 
only a part of the phenomena which characterize inflammation in the 
cornea and all other tissues, as, later, the fixed tissue-cells participate in 
the process, and the new cells derived from them form a part of the in- 
flammatory products. The parenchymatous changes are even more im- 
portant than the vascular, as repair after subsidence of inflammation is 



INFLAMMATION OF NON- VASCULAR TISSUE. 117 

accomplished exclusively by proliferation of the fixed tissue-cells. 
E berth has demonstrated, by his accurate histological researches, that 
the corneal corpuscles near an eschar, made for the purpose of producing 
a keratitis, multiply by karyokinesis, and regeneration is effected exclu- 
sively by the embryonal cells derived from this source. The corneal 
corpuscles possess a high vegetative capacity — resembling in this respect 
the connective tissue, to which they bear a strong resemblance, having a 
similar embryological origin — and receive their nutritive supply through 
a sj^stem of lymph-channels or vascular spaces which are in intimate 
relationship with the sclerotic vessels at the border of the cornea. The 
plasma or lymph-channels in the cornea are loosely filled with a liquid 
albuminoid substance, in which can be seen, even in a normal condition, 
occasionally, a lymph-corpuscle. In artificial keratitis these channels 
are first packed with leucocytes, which escape from the congested 
capillaries at the limbus cornese, enter them directly, and wander toward 
the seat of irritation far in advance of the new blood-vessels. Infiltra- 
tion of the cornea with leucocytes gives rise to cloudiness. At first 
Cohnheim claimed that infiltration of the cornea always occurred from 
the periphery, but in some of the later experiments on the corneae of 
spring frogs he noticed cell accumulation around the central eschar made 
with a sharp pencil of nitrate of silver, and, as he was absolutely opposed 
to the idea that the corneal corpuscles could take any active part in the 
process, he came to the forced conclusion that the cellular elements of 
the conjunctival fluid were increased, and that these had wandered into 
the cornea through the lesion at the centre. Strieker has observed 
karyomitotic changes in the corneal corpuscles surrounding a central 
eschar as early as three hours after cauterization, and, after twenty -four 
to forty-eight hours, cell proliferation was seen to be present all around 
the inflamed area. 

From what different authors have written on the subject of artificial 
keratitis, — which, of course, must be accepted as a fair representative of 
the clinical forms of this disease, — it becomes apparent that the first 
evidence of inflammation is an increased amount of fluid in the vascular 
spaces, causing distension and, consequently, swelling of the cornea. As 
the plasma canals become distended the cells lining them are in part de- 
stroyed, and the fluid escapes between two laminae and forces them partly 
asunder. (Fig. 65, C, C.) At this time the endothelial cells and corneal 
corpuscles undergo tissue proliferation, and the new cells form part of 
the inflammatory product. With the breaking down of the vascular 
spaces resulting in lymph stasis, accumulation of lymph-corpuscles also 
takes place, by which another cellular element is added to the inflamma- 
tory product. The plasma channels and artificialty-formed spaces 



118 



PRINCIPLES OF SURGERY. 



between laminae are now blocked with leucocytes, lymph-corpuscles, and 
embryonal cells. If the irritation is prolonged for a sufficient length of 
time, vascularization of the inflamed cornea will take place, in the course 
of one or two weeks, by the formation of new vessels from pre-existing 
sclerotic vessels at the corneal border. The new blood-vessels grow in 
the direction of the seat of irritation, occupying a triangular field, with 
the apex directed toward the centre, the base corresponding to the limbus 




Fig. 65.— Artificial. Keratitis, Kitten. Silver-staining, X 450. (Hamilton.) 

A. isolated and nucleated cell ; B, a group of such still retaining something of the shape of a plasma 
canal ; C, C, plasma canals breaking into fragments ; D, the fibrous basis of the lamellae, or the ground- 
substance. 

cornese. The vascular portion of such a cornea is called a pannus. In 
suppurative keratitis the nuclei emigration corpuscles undergo fragmen- 
tation and the corpuscles are converted into pus-corpuscles ; at the same 
time the embryonal cells exposed to the action of the pus-microbes fur- 
nish another histological source for pus production. The fibrous tissue 
within the suppurating area necroses, on account of the disturbed nu- 
trition and the toxic effect of the pus-microbes and their ptomaines, and 



INFLAMMATION OF NON- VASCULAR TISSUE. 119 

an abscess results. Vascularization of an inflamed cornea furnishes one 
of the most beautiful illustrations of the presence of protective resources 
in the organism, which, when called upon to meet different emergencies, 
render material aid in the prevention or limitation of destructive proc- 
esses. Every oculist is familiar with the fact that extensive suppurative 
keratitis manifests no tendency to reparative action when conditions are 
present that retard or completely prevent the formation of a pannus. 
As soon as the process of repair has been completed the new vessels dis- 
appear, leaving a transparent cornea if the defect has been within the 
limits of the regenerative capacity of the tissues ; in case the loss of 
substance has been too great for complete restoration of structure and 
function, healing is accomplished by the formation of ordinary cicatricial 
tissue, which results in the formation of a scar, — a permanent opacity of 
the cornea. In keratitis without suppuration, or attended by a limited 
ulceration, the cloudiness of the cornea resulting from cell infiltration 
and the presence of embryonal cells in moderate abundance, transparency 
is restored with the removal of the wandering cells bj^ granular degener- 
ation and absorption, or their return into the circulation, and the repair 
of the lesion by the transformation of the embryonal cells into mature, 
perfect, corneal tissue. 

Cartilage. — Cartilage is a structure not only devoid of blood-vessels, 
but also of any kind of vascular spaces for plasma circulation. Nutrition 
must here take place by inter- and intra- cellular diffusion of plasma. In 
its structure it resembles the cornea. On account of the absence of any 
direct or indirect connection of cartilage-tissue with the vessels of the 
perichondrium all regenerative processes are slow and imperfect, and the 
inflammatory lesions, which only occasionally are found here as a primary 
affection, are noted for their chronicity. Artificial chondritis was studied 
by Goodsir and Redfern. Certain parenchimatous changes were noted 
at different times after cauterization of articular cartilage. They consist 
essentially in the enlargement of the cartilage-cells, with increase of the 
nuclei, or of peculiar corpuscles contained in them, or with fatty degen- 
eration of their contents and fading or similar degeneration of their 
nuclei. The hyaline intercellular substance at the same time splits up 
and softens into a gelatinous and finely molecular and dotted substance. 
When molecular disintegration or ulceration of cartilage takes place, the 
enlarged cartilage-cells on the surface are liberated and the cement-sub- 
stance disappears in a similar manner after having undergone liquefaction. 
Kiiss stated that he had recognized, in articular cartilage under the influ- 
ence of irritants, certain fibrous transformations, and believed that he 
had seen, in one case, changes taking place within the cartilage-cells. If 
articular cartilage be examined in the neighborhood of an ulcerated spot, 



120 PRINCIPLES OF SURGERY. 

a complete separation of the fibres — the existence of which in its lami- 
nated structure was demonstrated by Thin, by a special method of silver- 
staining — and its reversion to ordinary white fibrous tissue can be readily 
made out. 

Weber describes new vessels as extending not only over the surface 
of the ulcerating cartilage, but afterward penetrating its substance. In 
long-standing ulceration of cartilage a well-marked pannous condition is 
usually found present, which has resulted from the development of new 
blood-vessels from the vessels of the perichondrium, which grow in the 
direction of the inflammatory focus in the same manner as in keratitis. 
Defects of cartilage caused by inflammation, like defects resulting from 
a trauma, are only partially repaired on account of the low vegetative 
capacity of the cartilage-cells, and the product of tissue proliferation is 
transformed into connective tissue. 

PHAGOCYTOSIS. 

It has been known for a long time that absorbable aseptic tissues in 
the living body are capable of removal by the action of certain cells. 
The absorption of aseptic catgut ligatures by leucocytes and embryonal 
cells, which accumulate around it and, later, infiltrate it, affords a good 
illustration of this. Metschnikoffs paper on phagocytosis was published 
in 1884, three years after Sternberg had placed himself on record in 
reference to the destruction of pathogenic microbes by leucoe3'tes. In 
1881 the latter author, in a paper read before the American Association 
for the Advancement of Science, used the following language: — 

"It has occurred to me that possibly the white corpuscles may have 
the office of picking up and digesting bacterial organisms which by any 
means find their way into the blood. The propensity exhibited by the 
leucocytes for picking up inorganic granules is well known, and that they 
may be able not only to pick up, but to assimilate and so dispose of the 
bacteria which come in their way does not seem to me very improbable, 
in view of the fact that amcebse, which resemble them so closely, feed 
upon bacteria and similar organisms." 

Metschnikoff has introduced the term phagocytosis to designate a 
process by which leucocytes and other cells remove dead material and 
destroy or digest pathogenic microorganisms. The cells which perform 
these functions he calls phagocytes. The leucocytes are called mikro- 
phagi,and the fixed tissue-cells, which are capable of performing the same 
function, makrophagi. Pigment-granules, minute fragments of tissue, 
and microbes gain entrance into a cell, either by the projections which 
are thrown out by amoeboid cells surrounding and inclosing them (intus- 
susception) or, in the absence of amoeboid movements, by a special 



PHAGOCYTOSIS. 121 

property of the cells, by which they take up into their protoplasm solid 
particles of various kinds. The cells which are known to possess phago- 
cytic properties are the leucocytes, mucous corpuscles, connective-tissue 
cells, endothelia of blood-vessels and lymphatic vessels, alveolar epithe- 
lium of the lungs, and the cells of the spleen, bone-marrow, and lymphatic 
glands. One of Metschnikoff's first experiments consisted in introducing 
under the skin of an insusceptible animal — the frog — a fragment of tissue 
from the liver or spleen of an anthracic animal. The implanted piece, 
when examined a couple of days later, was coated with a gelatinous 
exudation, full of leucocytes. These leucocytes were charged with bacilli, 
which he observed to be in various stages of degeneration. If the animal 
was kept at an ordinary temperature no harm resulted, but if it was ex- 
posed at the time and subsequently to a temperature of 38° C. the leuco- 
cytes, paralyzed by so high a temperature, failed in their phagocytic action, 
the bacilli multiplied, and the frog inevitably died. A much more accurate 
and convincing experiment was made, consisting in the introduction under 
the skin of the same animal a membranous tube — made of the lining of a 
species of large grass which grows on the banks of rivers (phragmites) 
— containing spores of bacillus anthracis. Soon the little tube filled with 
lymph, but contained no leucoc3^tes, for to them the membrane is imper- 
meable. A similar experiment was made with another tube, of which the 
ends were left open so that leucocytes could enter. In a day or two both 
tubes were examined. The contents of the closed tube swarmed with 
virulent bacilli. In the open tube the spores had been so effectually 
disposed of by the leucocytes that the contents could be inoculated into 
susceptible animals without effect. Metschnikoff next studied phago- 
cytosis in the tail of the tadpole, and found that the separation of this 
organ at the time this animal is developed into a frog is accomplished by 
leucocytes. At the time when the hind legs begin to bud the leucocytes 
migrate into the tail, and at the point where separation is to take place 
they attack the tissues, minute fragments of which may be seen in the 
interior of their protoplasm. In the daphnia, the common water-flea, he 
studied the destruction of a fungus with which these insects are prone 
to be infected, — by the mikrophagi. When phagocytosis proved success- 
ful he witnessed the destruction of the fungus in the interior of leuco- 
cytes ; on the other hand, when the fungi were present in such large 
numbers that the leucocytes were unable to destroy or digest them, the 
daphnia died. Next, he investigated phagocytosis in a number of 
diseases, — erysipelas, anthrax, relapsing fever, and tuberculosis. In 
erysipelas the cocci are first attacked by the leucocytes filling the lymph- 
spaces, and, later, by the fixed connective-tissue cells. In the path of 
destruction he saw leucocytes loaded with cocci, the latter showing 



122 PRINCIPLES OF SURGERY. 

various stages of dissolution. The connective-tissue cells were also 
engaged in the removal of disintegrated leucocytes. In fatal cases of 
erysipelas the streptococci multiplied with such great rapidity that the 
phagocytes were unable to cope successfully with the disease. Ribbert 
experimented with the spores of aspergillus and mucor, and the results 
were such that he claimed that spores in the interior of leucocytes, the 
connective tissue of the liver, and the giant cells which develop in the 
liver and in the lungs are destroyed, but that their destruction is not 
owing so much to phagocytic action of the cells as to the exclusion from 
them of nourishment for the spores, particularly of oxygen. Laer 
injected into the lungs through the trachea cultures of the staphylo- 
coccus in rabbits, with the result of causing a catarrhal inflammation. 
The cocci were removed by leucocytes and the embryonal epithelia of 
the alveoli. During the first week these cells contained many cocci, but 
during the second week they disappeared in the cells, and the animals 
recovered. 

Metschnikoff's doctrine of phagocytosis has met with violent oppo- 
sition by a number of eminent pathologists, and foremost among them 
we find Baumgarten. In a number of publications this author has 
taken a positive and firm stand against the claim that cells have the 
power to digest or destroy the microbes which inhabit their protoplasm. 
Holmfeld, Bitter, Prudden, and Nuttal have also arrayed themselves 
against Metschnikoff. With some modifications Klebs is a believer in 
phagocytosis. In a very interesting paper on this subject Osier gives 
the result of his own observations on the phagocytic action of the cells 
lining the bronchial tubes and the alveoli of the lungs. He shows very 
conclusively how minute foreign particles are eliminated by means of 
the phagocytic action of the cells. In connection with the subject of 
inflammation, the doctrine of phagocytosis should be employed in a wider 
sense than was assigned to it by Metschnikoff. In the first place, the 
accumulation of leucocytes at the seat of inflammation must be consid- 
ered in the light of a mechanical barrier, — an attempt to protect the 
tissues against infection. Unfortunately, in acute inflammation, this wall 
is usually more apparent than real, as the microbes become diffused 
through the plasma-stream, and are transported by the leucocytes them- 
selves ; hence the progressive nature of the process. The connective- 
tissue proliferation proves more successful than emigration in limiting 
the dissemination of microorganisms in the tissues, as the new cells, so 
long as they remain attached to the matrix which produces them, remain 
stationary, and mechanically block the avenues through which dissem- 
ination takes place. It is the impermeable wall of granulation tissue 
that surrounds a suppurating depot which finally limits suppurative 



PHAGOCYTOSIS. 123 

inflammation. In the next place, the phagocytes are scavengers which 
remove foreign dead particles from the tissues. Langhans was the first 
to show that extra vasated blood did not simply disintegrate and disap- 
pear, but that the connective-tissue elements were actively at work, and 
that many of the colored corpuscles disappear in their interior. Rosen- 
berger implanted stained aseptic tissue into the abdominal cavity of 
animals, and, on examining the parts a few weeks later, found that 
not only had the tissues been completely removed by leucocytes, but 
he was able to follow the course of the leucocytes, after they had left 
the feeding-ground, by colored lines, all of which were seen to radiate 
from the place where the stained tissue had been fixed. In different 
pathological conditions where tissue proliferation was in process, Klebs 
could find positive evidence that wandering cells that had undergone 
fragmentation had been appropriated by the embryonal cells as food, as 
fragments of the nuclear chromatin of the leucocytes could be discov- 
ered in the protoplasm of the new cells. In the reparative process 
which follows the subsidence of inflammation, a great deal of cellular 
debris is to be removed, and this work is performed by the phagocytes, 
notably by the fixed tissue-cells in a state of proliferation. The vege- 
tative capacity of the cells is augmented by the reception into their 
protoplasm of nutritive material furnished them by cells which have 
succumbed in the struggle. Metschnikoff believed that the destruction 
of microorganisms in the interior of phagocytes was an active process, 
and that the protoplasm had a sort of digestive action upon them. To 
prove the correctness of this supposition he made some experiments 
with the bacillus of tuberculosis. He injected a pure culture of the 
bacilli into the subcutaneous tissue of white rats, and, later, produced 
artificially suppuration at the seat of injection. Two months later he 
found bacilli in the pus-corpuscles in an unchanged condition, and with- 
out having lost their power of reproduction. As in other experiments 
he had witnessed the destruction and disappearance of the same bacillus 
in living cells, he concluded that phagocytosis is an active process which 
can only take place in a living cell, and is suspended with the death of 
the cell. In mouse-septicaemia and in gonorrheal pus many of the 
leucocytes are stuffed with microbes, while others do not contain a single 
bacterial cell, — a condition which would tend to prove that the bacterial 
contents in each leucocyte were the offspring of a single microbe, and 
could be advanced as an argument against the phagocytic action of the 
leucocytes. On the other hand, the bacilli in the interior of leucocytes 
in anthracic animals present evidences of degeneration, which speaks in 
favor of the phagocytic theory. 

In 1890 Metschnikoff summarized, at the close of a lecture on this 



124 PRINCIPLES OF SURGERY. 

subject, his convictions as follows : " It is not possible at the present time 
to state fully and accurately all those influences which are associated in 
aiding phagocytic action, but already we have the right to maintain that, 
in the property of its (the blood) amoeboid cells to include and to destroy 
microorganisms, the animal body possesses a formidable means of re- 
sistance and defense against these infectious agents." 

There are a few at this time who regard the destruction and dis- 
appearance of microbes in phagocytes as an act of digestion. If, how- 
ever, microbes in the interior of phagocytes are rendered harmless or 
disintegrate and disappear, this fact is an important one, and it is im- 
material in what way this result is obtained, whether the microbes are 
digested by the protoplasm, or whether some chemical substance in the 
cell-body exerts an inhibitory effect upon them, or, finally, whether for 
want of a proper nutrient material they are starved, as it were. The 
results of experimental research have furnished positive evidence that 
infective processes terminate most favorably where the conditions de- 
scribed as phagocytosis are accomplished most satisfactorily. 

When the struggle between a microbe and a phagocyte turns out in 
favor of the latter, the microbe does not multiply in the protoplasm, or 
ceases to do so before the protoplasm is destroyed, and, as the microbe 
cannot leave without dissolution of the cell, it remains within its narrow 
confinement and is destined, either by some as j T et unknown chemical 
substance or dies from starvation ; in either event the vitality of the 
cell is not impaired and the microbe disintegrates and disappears. 
(Fig. 66, A.) If the conditions for the growth and development of the 
microbe in the protoplasm of the cell are more favorable, intra-cellular 
multiplication of the microbe takes place, the ptomaines which are 
eliminated produce coagulation necrosis in the protoplasm, the cell 
disintegrates, and the intra-cellular culture is liberated in an active con- 
dition (Fig. 66, B). In cases of unsuccessful warfare of the phagocytes 
against invading microorganisms, the mechanical obstruction composed 
of emigration corpuscles and embryonal cells is broken down, and the 
rapid increase of microorganisms at the seat of inflammation gives rise 
to extensive local and often general infection. From a practical stand- 
point it can be said that all therapeutic measures which influence favor- 
ably the process of phagocytosis, in the broadest meaning of this word, 
are calculated to exert a potent influence in arresting or limiting infective 
processes. 

CHRONIC INFLAMMATION. 

Chronic inflammation differs from the acute form only in degree. 
The vascular changes which have been described come on slowly, and 



CHRONIC INFLAMMATION. 



125 



are never so marked as in acute inflammation ; and on this account the 
emigration of blood-corpuscles occurs slowly, and in some instances it 
is entirely wanting. The inflammatory product is largely, and in some 
cases exclusively, composed of embryonal cells derived from fixed 
tissue-cells. The noxae which excite chronic inflammation are such that 
exert their deleterious effect more on the tissue-cells directly than the 
capillary vessels. Their primary action on the tissues consists in 
increasing the vegetative capacity of the cells ; hence, mature cells are 
transformed into embryonal or granulation tissue and remain in this 
condition as long as the noxae exist, and retain their pathogenic qualities 
or otherwise until the new cells undergo retrograde metamorphosis. If 
in a chronic inflammation degeneration of the embryonal cells has not 
taken place, and the primary cause has ceased to act, the new tissue is 





B 



Fig. 66.— Phagocytosis. Struggle [between Anthrax Bacillus and Leucocyte. 

A, successful phagocytosis ; B, unsuccessful phagocytosis. 

either removed by absorption or is converted into mature tissue, in 
which event the inflammation has resulted in hyperplasia. Syphilitic 
gummata, which are composed almost exclusively of embryonal tissue, 
disappear promptly under a vigorous antisyphilitic treatment, because 
by such treatment the microorganisms which have caused the lesion 
are either destroyed or at least have been deprived for the time being of 
their pathogenic properties. 

Chronic inflammation is represented by that large class of affections 
which are included under the name granulomata. These swellings, irre- 
spective of their primary microbic cause, are composed of what is known 
as granulation tissue. Some pathologists have been inclined to classify 
them with tumors because their development is seldom attended by 
well-marked symptoms of inflammation, and in their methods of regional 



126 PRINCIPLES OF SURGERY. 

and general dissemination they bear a close resemblance to the malignant 
tumors. Their obstinacy to successful treatment does not depend upon 
any malignant qualities of the tissues of which they are composed but 
upon the difficulty of eliminating or rendering inert the primary cause 
by internal medication or operative procedures. 

All granulomata are inflammatory in their origin, and under the 
microscope present all the characteristic appearances of inflammation. 
Histologically they are composed of embryonal cells which correspond 
to the type of the tissues in which or from which they have developed. 
In a tubercular nodule we find giant cells, epithelioid cells, the ordinary 
granulation cell, and leucocytes. Actinomycotic swellings are composed 
almost exclusively of embryonal connective tissue. Many of the granulo- 
mata contain Ehrlich's plasma-cells (Mastzellen), of unknown origin, 
composed of a finely-granular mass around a vesicular nucleus. On 
staining with aniline colors, the nucleus remains unchanged, while the 
granules are deeply stained. The cells are about the size of a leucocyte, 
either spherical or somewhat elongated in shape. In some cases the 
outer portion of the inflammatory product, being sufficiently remote 
from the infected area, is converted into a firm connective-tissue capsule, 
which limits the extension of infection, while in its interior, from the 
presence of the specific microorganisms, but probably more on account 
of inadequate blood-supply, the tissues undergo rapid retrograde 
degenerative changes. 

Secondary infection in a granuloma, either through the circulation 
or, what is more common, from without, through some minute infection- 
atrium, is a not uncommon occurrence. Secondary infection almost 
always means localization of pus-microbes in the granulation tissue and 
a breaking down of the latter into pus corpuscles. The serious conse- 
quences which follow suppurative inflammation of a gumma developing 
after incision made upon a wrong diagnosis is well known. Infection of 
a large tubercular depot with pus-microbes after incision without proper 
antiseptic precautions, or after spontaneous evacuation, is followed by 
destruction of the remaining granulations, profuse suppuration, and not 
infrequently by death from sepsis. Actinon^cosis gives rise to a large 
granuloma without any tendency to suppuration until infection takes 
place with pus-microbes, when the granulations melt away rapidly, 
leaving a deep ulcer with ragged, undermined margins, and a speedy 
extension of the combined infective processes following in its course the 
connective tissue. 

The secondary infection, however, may prove beneficial and become 
the means of complete elimination of the inflammatory product and 
microorganisms of the primary infection. In this way a localized 



SYMPTOMS AND DIAGNOSIS OF INFLAMMATION. 127 

tubercular lesion is sometimes cured spontaneously by suppuration. A 
suppurative inflammation of a tubercular gland of the neck is often 
followed by complete removal of the bacilli-containing tissues and a 
permanent cure. All chronic inflammatory processes are attended by 
recurring attacks of acute exacerbations. If during these attacks in the 
periphery of the chronically-inflamed area a more active cell proliferation 
is initiated, the conditions for a more successful phagocytosis are 
improved and the acute attack has proved a curative measure. 

The surgeon often resorts to measures which result in the transfor- 
mation of a chronic into an acute inflammation, in imitation of nature's 
efforts in the same direction. In illustration of this, I will only mention 
ignipuncture. The fenestration of a chronic inflammatory swelling 
under strict antiseptic precautions has proved a valuable therapeutic 
measure by securing drainage, but more especially because around each 
tubular eschar made with the needle-point of a Paquelin cautery a zone 
of active tissue proliferation is created, and the new tissue, by under- 
going transformation into cicatricial tissue, serves a useful purpose in 
starving out microbes that have escaped the cautery. Another instruc- 
tive instance of the benefits which accrue from the substitution of an 
acute for a chronic inflammation is found in the use of jequirity in 
ophthalmic practice. The powdered bean or some other preparation of 
this drug, when brought in contact with the conjunctiva, produces a 
violent inflammation which lias frequently proved a curative measure in 
the treatment of trachoma and some forms of pannus of the cornea. 

One of the ways in which an acute inflammation acts beneficially in 
promoting the process of resolution in tissues the seat of a chronic 
inflammation is by its stimulating action on the capillary vessels. The 
active hyperemia may become the means of clearing partially-obstructed 
capillary vessels of implanted colorless corpuscles, and thus remove from 
the weakened tissues not only the mechanical causes which have main- 
tained the chronic congestion, but also the intra-vascular cause of the 
inflammation, — the microbes. When the infected corpuscles reach the 
general circulation there is a chance for more effective phagocytosis and 
elimination of the microbes through one or more of the excretory organs. 

SYMPTOMS AND DIAGNOSIS OF INFLAMMATION. 

For practical purposes, inflammation ma}' be divided into acute, 
subacute, and chronic, according to the intensity of symptoms and the 
time required to reach one of its terminations. The nature of the pri- 
mary cause determines the course and nature of the inflammation. The 
microbes of suppuration, erysipelas, anthrax, glanders, tetanus, and 
gonorrhoea cause acute affections, while the microorganisms of tubercu- 



128 PRINCIPLES OF SURGERY. 

losis, lepra, and actinomycosis cause lesions which are noted for their 
chronicity. Acute inflammation may become subacute and finally 
chronic, as in suppurative osteomyelitis, where, if the disease is multiple, 
in the first bone affected it pursues a very acute course ; while often in 
the successive bones attacked it is less intense, and not infrequently in 
the last bone involved it appears as a chronic affection. A chronic in- 
flammation may be followed by a subacute or acute attack, as is fre- 
quently observed in tuberculosis complicated by secondaiy infection 
with pus-microbes. In acute inflammation the local and general s3 T mp- 
toms are so well marked that no difficulties are in the way of recogniz- 
ing its existence, and it only remains to decide upon its character. The 
fever which attends the inflammation is only a symptom, and indicates 
the introduction into the general circulation of phlogistic substances 
from the products of exudation or the fixed tissue-cells which have 
undergone pathological changes. Microbes that cause acute inflamma- 
tion differ greatly as to the amount or intensity of action of the phlo- 
gistic substances which they produce in the inflamed tissues affected ; 
also exert an important influence in modifying the febrile disturbance. 
Suppuration caused by the micrococcus pyogenes tenuis is not attended 
by so high a temperature as when produced b} r the staphylococcus or 
streptococcus. The rise in temperature which accompanies inflammation 
is due either to the introduction into the circulation of fibrin ferment 
resulting from the destruction of leucocytes or the production of pto- 
maines by the specific action of microbes on the tissues, which act as 
phlogistic substances when introduced into the general circulation, — a 
fact which has been abundantly demonstrated by clinical observation 
and experimental research. As soon as the causes which have produced 
the rise in temperature in inflammation have been rendered inert by phago- 
cytosis, or have been eliminated with the removal of the inflammatory 
product, the fever subsides. The general disturbances, such as headache, 
vomiting, loss of appetite, thirst, and the ever-present feeling of lassitude 
which attends acute inflammation of all kinds, are caused by the fever 
and the presence of toxic substances in the blood. The S3 T mptoms of 
inflammation, which have been described at length, must be studied sep- 
arately and conjointly in each form of inflammation, and their individual 
and mutual significance carefully estimated. A local rise in temperature 
is of more diagnostic value in ascertaining the existence of inflammation 
than fever, as the latter can be caused by the absorption of fibrin ferment 
from any causes which destroy the colorless blood-corpuscles and the 
absorption of the products of tissue disintegration in malignant tumors; 
while a permanent increase of the temperature at the seat of the disease 
denotes almost infallibly the existence of inflammation. In reference to 



PROGNOSIS. 129 

the extension of the inflammatory process, it can be said that this will 
be influenced D3 r the anatomical structure of the part involved and the 
manner of diffusion of the microbe which causes the inflammation. If a 
mucous or serous surface is affected, infection is prone to spread rapidly 
by continuity of tissue and the mechanical dissemination of the microbes 
on the surface in the mucous secretion, and by the movements of one 
serous surface upon the other. In erysipelas the inflammation spreads 
rapidly, as the microbe is diffused through the lymphatics and connective- 
tissue spaces. In phlegmonous inflammation the pus-microbes find no 
mechanical barriers, and are rapidly distributed over a larger area 
through the connective-tissue spaces. The same manner of diffusion is 
observed in anthrax if the bacillus finds ingress into a part supplied 
with an abundance of loose cellular tissue, while the disease remains 
circumscribed and presents itself in an indurated form if it is located 
in tissues which do not present such favorable anatomical conditions for 
extension of the local invasion. The nature of the inflammatory product 
always answers to the specific action of the microbe in the tissues 
which caused the inflammation. Thus, an inflammation caused by pus- 
microbes will result in the formation of pus ; while the microbes which 
produce chronic inflammation, as a rule, only convert the pre-existing 
mature into embryonal tissue. The microbes which have a short exist- 
ence in the tissues may give rise only to intense l^persemia and a mod- 
erate emigration of the colored blood-corpuscles, as, for instance, the 
streptococcus of erysipelas. The genuine, uncomplicated erysipelatous 
inflammation is of such short duration that perfect restoration of the 
parts is accomplished in a few days. 

PROGNOSIS. 

The most favorable termination of inflammation is resolution, with 
restitutio ad integrum of structure and function of the tissues which 
were the seat of the inflammatory process. Resolution is only possible 
if the emigration of blood-corpuscles is moderate in quantity and none of 
the cellular elements of the exudate are transformed into pus-corpuscles. 
If exudation take place rapidly, the connective-tissue spaces are com- 
pletely blocked with the emigration corpuscles and the products of 
coagulation necrosis, which seriously impairs or completely arrests 
plasma circulation, and, by pressure upon the blood-vessels, may interfere 
with the capillary circulation to such an extent as to cause necrosis. 
Resolution, as has been previously stated, signifies that, after subsidence 
of the symptoms of inflammation, the part is left in a condition capable 
of removing the inflammator} 7 product and of repairing the damage done. 
Many of the leucocytes which have retained their vitalit}' immigrate 



130 PRINCIPLES OF SURGERY. 

back into the general circulation either through the walls of capillaries 
or, what is more frequent, through the lymphatic system. The remain- 
ing leucocytes and colored corpuscles undergo degeneration and are 
removed by absorption. Fibrin which has formed in the tissues is trans- 
formed into a granular mass and is removed in a similar manner. 
Embryonal cells which have become detached, or have been damaged by 
the inflammation, are also removed by absorption after they have under- 
gone granular degeneration. The transudation is removed by absorp- 
tion as soon as capillary circulation is restored and the connective-tissue 
spaces have been cleared of their cellular contents. The capillar}' wall 
is repaired, and any tissue defects are restored by proliferation of the 
fixed tissue-cells. The inflammatory exudate may prove a source of 
danger when, by its mechanical pressure, it interferes with the function 
of important organs, as the brain, heart, or lungs. A moderate transu- 
dation within the skull from inflammation of any of the meninges can 
produce death from compression of the brain; a pericardial effusion, 
when sufficient in amount to interfere mechanically with the action of 
the heart, causes death by syncope ; and a copious effusion into the 
pleural cavity, especially if it come on rapidly, may impair respiration 
to such an extent as to result in death from apnoea. A slight croupous 
exudation upon the vocal cords or oedema about the entrance to the 
larynx destroys life by preventing, in a purely mechanical way, the en- 
trance into the lungs of an adequate quantity of air. Inflammation is 
greatly modified by the age and general condition of the patient. Infants 
and persons advanced in years possess little power of resistance, and, 
when attacked by inflammation, the disease is prone to become diffuse 
and lead to serious pathological changes. The same can be said of 
persons who have been debilitated by antecedent diseases or intemperate 
habits. The greatest danger in the different forms of inflammation, as 
far as life is concerned, consists in the introduction into the general cir- 
culation of septic material produced in the inflamed part by the action 
of microbes on the tissues. This general infection, occurring in the 
course of a localized inflammation, appears either as a sj'mptomatic fever, 
which disappears with the subsidence of the local process, or as a pro- 
gressive septicaemia, pyaemia, or septico-pysemia, The latter diseases 
will be considered in separate chapters. Tubercular affections are alwa3 T s 
attended by the danger incident to extension of the process to other 
organs by dissemination of bacilli through the lymphatic channels or 
blood-vessels. Chronic suppuration finally causes amyloid degeneration 
of important organs and death ensues from this cause. In summing up 
what has been said under this head, it is evident that the prognosis rests 
mainly upon the intrinsic pathogenic qualities of the microbe which has 



TREATMENT. 1 31 

caused the inflammation; the anatomical structure, location, and physio- 
logical importance of the part or organ inflamed ; the general condition 
of the patient, and the accessibility to and feasibility of treating the 
disease by direct radical surgical means. 

TREATMENT. 

As inflammation per se is no disease, but an effort on the part of the 
organism and the tissues affected to eliminate or render harmless the 
primary cause, the treatment must be, in each individual case, purely 
symptomatic. A proper appreciation of the nature and tendencies of 
inflammation is an essential prerequisite to rational treatment. In 
surgery the prophylactic treatment of inflammation is the most important 
and satisfactory. The prevention of inflammation in accidental and oper- 
ation wounds by strict antiseptic precautions has made modern surgery 
what it is. The surgeon has it now in his power, by resorting to anti- 
septic measures, to prevent the innumerable and formerly too often fatal 
wound complications. Lister has inaugurated a new era in surgery, and 
his work, as well as that of his early enthusiastic followers, has been the 
means of saving annually thousands of lives. The mortality of even 
the most desperate operations, where the antiseptic treatment can be 
followed to perfection, has been so much reduced that operative surgery 
has received a new impetus, and operations are devised and put in prac- 
tice almost daily which formerly would have been looked upon as a 
freak of imagination or the outcome of a diseased brain. The prophy- 
lactic treatment of inflammation in dealing with wounds, or other avenues 
through which infection can take place, consists of securing for the 
place deprived of the effective protection against the entrance of patho- 
genic microorganisms — the intact skin or mucous membrane — an aseptic 
condition by antiseptic measures, and to bring in contact with it only 
things that have been thoroughly sterilized. 

In inflammation without an external tangible infection-atrium we 
must take it for granted that microbes have entered the circulation 
through slight defects the existence of which, perhaps, the patient does 
not remember, and which have left no appreciable marks of their former 
existence, or infection has taken place through some of the appendages 
of the skin or through a mucous membrane, with localization of the 
microbes in a part or organ previously prepared for their reception and 
growth ; that is, in a location presenting a locus minoris resistentise. 

Recognizing the fact that inflammation, wherever it occurs, is pro- 
duced by the action upon the vessel-wall and the tissues outside of it of 
specific microorganisms, it would appear that the most rational indica- 
tion for treatment would be to resort to such means as would destroy 



132 



PRINCIPLES OF SURGERY. 



the microbes in the tissues as soon as their presence is manifested by their 
action. This would imply the saturation of the inflamed tissues with ger- 
micidal solutions,which from laboratory experiments are known to be effect- 
ive in destroying, or at least inhibiting the growth of, such microbes ; 
hence, it has been advised to resort to 

Parenchymatous Injections. — This method of treatment was strongly 
advised and extensively practiced by Hueter long before the direct 
relationship between certain microbes and definite forms of inflammation 
had been demonstrated. Hueter claimed that every inflammation was 
caused by certain noxse introduced from without, and 
which he aimed to destroy by saturating the inflamed 
tissues with an antiseptic solution. His favorite 
remedy was a 3- to 5-per-cent. solution of carbolic 
acid. The instrument which he used was an ordinary 
Pravaz syringe, with a long needle provided with a 
number of small lateral openings. In adults he 
injected as much as 10 grammes at a time of a 3-per- 
cent, solution. In using this method in the treat- 
ment of large, granulating, tubercular foci he 
employed what he termed an in/user, composed of a 
graduated glass cylinder, joined with the needle by 
means of a rubber tube. By this method of injec- 
tion the fluid diffused itself through the soft, granular 
mass by its own weight. In the treatment of tuber- 
cular lesions Hueter claimed for the parenchymatous 
injections of carbolic acid great curative powers. 
Rational as this method of treatment appears, it has 
not yielded the results that were anticipated. The 
living tissues cannot be compared with a test-tube. 
Nitrate of silver, iodine, permanganate of potassa, 
corrosive sublimate, and other potent germicidal 
agents have been used since, but the results, on the 
whole, have been anything but satis factoiy. If this 
method of treatment is to be successful in the treatment of acute inflam- 
mation, it must be instituted at an early stage, at a time when only a 
limited area of tissue has been infected, as, under such circumstances, 
if the area of infection could be accurately outlined, it would be possible 
to saturate the tissues with an antiseptic solution without running the 
risk of killing the patient by administering a toxic dose of the drug 
employed, which might be the case if a larger area were treated in a 
similar manner. If we remember that the microbes are diffused through- 
out the entire exudation and constitute the most important element of 




Fig. 67.— Hueter's 
Infuser. 



TREATMENT. 133 

the inflammatory product, it is easy to understand that sterilization of 
the inflamed tissues by means of parenchymatous injections is not an 
eas}' task, and we are then in a position to realize why this method of 
treatment has not proved more uniformly successful. Most of the germi- 
cidal agents heretofore employed in this manner, when brought in contact 
with the tissues, form compounds which prevent further diffusion, and 
therefore each needle-puncture sterilizes only a very small portion of the 
inflamed district. It is possible that in the future non-toxic, but at the 
same time effective germicidal, substances will be discovered which can 
be used in larger quantities, and in this event the treatment of inflamma- 
tion by parenchymatous injections will have a wide range of application, 
and will be practiced with better success. At present this method has a 
limited field of application in the treatment of the various forms of in- 
flammation. Under no circumstances should the amount of the drug 
used exceed the dose which it would be safe to administer internally, and 
the danger of a poisonous dose should be remembered in repeating the 
injection. An ordinary hypodermic syringe with a long needle can be 
used in making the injection. That the needle and syringe should be 
perfectly aseptic is to be understood as a matter of course, as unclean 
instruments have often been the means of conveying a fatal disease. 
Multiple punctures are to be preferred, as in this manner, by using the 
same amount of fluid, more tissue can be saturated than by a single 
puncture. Before making the punctures the surface must be disinfected. 
The object should be to bring the antiseptic solution in contact with as 
much of the injected tissue* as possible, and if the disease manifests a 
tendency to spread it is advisable to go beyond the zone of infection, as, 
for instance, in cases of erysipelas and anthrax. A 5-per-cent. solution 
of carbolic acid is preferable to all other antiseptics in the treatment of 
acute inflammatory affections by this method. Many accessible tuber- 
cular affections are greatly benefited by parenchymatous injections of 
carbolic acid. Recently, intra-articular and parenchymatous injections 
of iodoform have been strongly recommended in the treatment of articu- 
lar and other forms of surgical tuberculosis. 

Antiphlogistic Treatment. — An erroneous conception of the nature 
and tendencies of inflammation has for centuries induced the ablest 
teachers and practitioners to advocate and practice what they termed the 
antiphlogistic treatment of inflammation. This included blood-letting, 
cupping, leeching, and the internal use of emetics and cathartics. It was 
urged that as inflammation is attended by an increase of heat, swelling, 
and redness, such remedies should be employed as will reduce arterial 
tension. Venesection is now seldom, if ever, resorted to in the treat- 
ment of any form of inflammation. An unimpaired vis a tergo is one of 



134 PRINCIPLES OF SURGERY. 

the best means to prevent stasis within the inflamed capillaries, and 
practical experience has shown that all remedies and agents which 
diminish the intra-arterial tension only diminish the prospects for a 
favorable termination of the inflammation. Cohnheim showed experi- 
mentally that the threatened stasis in the exposed mesentery of the frog 
was avoided by injecting into one of the veins 1 centimetre of a 6-per- 
cent, solution of sodic chloride. If, under similar conditions, a consider- 
able quantity of blood is abstracted, the congestion can be seen to 
terminate in a short time in complete stasis. While venesection in the 
treatment of inflammation has been discarded, the direct abstraction of 
blood from the inflamed part has proved a useful therapeutic resource. 
Nancrede divided a large vein on the distal side of the circulation in the 
tongue of a fi'9g, — the seat of an intense inflammation artificially pro- 
duced. He describes the tangible therapeutic effect as follows : " The 
effect upon the obstructed vessels was first an oscillation of the blood- 
discs, then an occasional momentary flow of blood, then suddenly a rapid 
resumption of the circulation, sweeping out the blood-vessels and appa- 
rently restoring them to their normal condition, except at spots where 
the agents inducing inflammation had chemically destroyed the vessels 
or coagulated their contents." Genzmer showed that in the inflamed 
mucous membrane of a frog scarification hastened resolution. In order 
to be of benefit the scarification must be made through the inflamed part, 
so as to unload directly the dilated and engorged capillar} 7 vessels, and 
on this account this method of treatment is only applicable when the 
inflammation is superficial and affects accessible parts. Leeches should 
never be used, as infection from this source has frequentl} 7 resulted dis- 
astrously. The scarificator used for cupping is difficult to keep aseptic, 
and the number and depth of the scarifications to be made are not under 
the control of the surgeon, and for these reasons this instrument has onPy 
an historical interest and antiquarian value. The scarification should be 
made with a sharp scalpel, and the bleeding encouraged by applying warm 
water. Scarification is followed by great relief in inflammation of acces- 
sible mucous membranes, and has recently been very strongly recom- 
mended in the treatment of erysipelas for the purpose of preventing the 
extension of this disease. 

In the different forms of septic inflammation attended by severe 
general symptoms the gastro-intestinal canal often participates in the 
process, and vomiting and diarrhoea become conspicuous and often dis- 
tressing symptoms. These sj^mptoms should not be checked, as they 
indicate an attempt on the part of the organism to eliminate through the 
gastro-intestinal mucous membrane microbes and ptomaines which have 
reached it through the general circulation. The surgeon should assist 



TREATMENT. 135 

this effort by administering a few doses of calomel, followed by a saline 
cathartic, which will often control the vomiting and diarrhoea more 
promptly by removing the cause than medicines employed to arrest the 
process of elimination. 

Physiological Rest. — One of the most urgent indications in the treat- 
ment of inflammation is to secure for the part affected a condition 
approaching physiological rest. In ulcerative affections of the gastro- 
intestinal canal the patient should abstain from taking food by the 
stomach. Fixation of the chest by means of broad strips of adhesive 
plaster affords great relief in pleuritis. An inflamed joint must be im- 
mobilized by some kind of a splint. A chronic cystitis usually yields 
to suprapubic or perineal drainage of the bladder after all other measures 
have failed. In inflammatory affections of the eye exclusion of light is 
one of the most essential features of successful treatment. Patients 
suffering from inflammatory affections of the tonsils, pharynx, and 
larjmx should use their voice as little as possible. In cases of acute 
inflammation of the brain or its envelopes the patient must be kept in a 
dark room, and absolute quietude enforced. 

Elevation of Inflamed Parts. — From the diminished vis a tergo on the 
distal side of the capillary vessels, venous engorgement is as pronounced 
as increased arterial tension on the proximal side of the inflamed capillary 
vessels, and elevation of the inflamed part improves the vascular dis- 
turbances by the force of gravitation favoring the return of venous 
blood. The importance of elevation of the inflamed part becomes 
manifest in the treatment of inflammatory affections of the extremities. 
In phlegmonous inflammation of the hands or feet the throbbing pain is 
always aggravated if the limb is kept in a dependent position, and 
promptly relieved upon placing it in an elevated position. Elevation 
not only alleviates the pain, but is at the same time the most effective 
means of removing the oedematous swelling. If necessary, elevation can 
be combined with suspension in order to secure more perfect rest for the 
inflamed part. In severe acute inflammation it is not only necessary to 
secure rest for the part inflamed, but of the whole body, and in such 
cases the patient must observe the recumbent position in bed, as all 
muscular movements and all unnecessary strain upon the blood-vessels 
cannot but be productive of harm by favoring the ingress into the circu- 
lation of microorganisms and their ptomaines from the seat of inflam- 
mation, or, perhaps, result in embolism from detachment of a portion 
of a thrombus, — an accident which possibly might not have occurred 
otherwise. 

Application of Cold. — Cold has been resorted to indiscriminately and 
empirically in the treatment of inflammation. Cold is a potent agent for 



136 



PRINCIPLES OF SURGERY. 



good or harm, according to the stage of inflammation during which it is 
employed. The sensation of heat, both subjective and objective, naturally 
suggested the use of this remedy. The application of cold is of great 
benefit during the earliest stage of inflammation, at a time when exuda- 
tion is only beginning and the capillary vessels are dilated and only 
partially obstructed. Cold, when applied under these circumstances, 
becomes a valuable remedial agent (1) by producing contraction of the 
small blood-vessels ; (2) by producing at least an inhibitory effect upon 
the microorganisms in the inflamed tissues. The contraction of blood- 
vessels which takes place under the application of cold has a tendency 
to clear the capillaries of their contents and to prevent further mural 




Fig. 68.— Cold Coil, after Esmarch. 



implantation. Microorganisms can only multiply at a certain tempera- 
ture, and if this can be kept at a point low enough to prevent their in- 
crease in the tissues by the application of cold this agent fulfills one of 
the causal indications in the treatment of inflammation. If, however, 
stasis has already taken place in the capillaries first affected the applica- 
tion of cold will prove harmful, as it will tend to prevent the formation 
of an adequate collateral circulation. Cold acts most beneficial^ when 
the inflammation is located in the superficial parts, but its prolonged use 
will reach even deep-seated structures, as the pleura, peritoneum, the 
brain and its envelopes, the joints and bones. When it appears desirable 
to resort to the use of cold, this remedy should be applied in the form 
of an ice-bag or cold coil. The part to which the ice-bag is to be applied 



TREATMENT. 



137 



can be covered with several layers of a wet towel, as otherwise the pro- 
longed use of the direct application of ice may freeze the skin. The 
sensations of the patient can usually be taken as a safe guide as to the 
length of time it should be continued. 

Antiseptic Fomentations. — The ordinary filthy poultice of flaxseed, 
slippery elm, or bread and milk has now no place among the resources 
of the aseptic surgeon. The common poultice is a hot-bed for bacteria, 
and, as such, it should be discarded. In the treatment of an ordinary 
furuncle with poultices, I am sure that almost every surgeon must have 
seen occasionally the development of innumerable minute daughter- 




FlG. 69.— COLD COIIi FOR THE HEAD, AFTER LEITER. 



furuncles on the surface covered by the poultice. In phlegmonous in- 
flammation of the fingers or hand the prolonged use of the poultice is 
followed by maceration of the skin, extensive oedema of the superficial 
structures, a flabby condition of the granulation, — in fact, all the evidences 
which point to the poultice as a means of favoring the extension of the 
infective process. When inflammation has passed beyond the stage 
where cold exercises a favorable influence, or where cold applications in- 
crease the suffering, warm antiseptic fomentations should be employed. 
The surface to which they are to be applied should be thoroughly 
cleansed with warm water and potash-soap. The antiseptic solution to 
be used should be selected according to the age of the patient or the 



138 PRINCIPLES OF SURGERY. 

area affected, with a special view of guarding against the absorption of 
a toxic dose of the drug employed. Acetate of aluminum, in the 
strength of 1 per cent, dissolved in sterilized water, is a safe preparation 
under all circumstances. Boric and salicylic acids are efficient and safe 
preparations. Greater care is necessary in the use of carbolic acid and 
corrosive sublimate, as, when concentrated solutions of these drugs are 
used for any length of time in infants, the aged, or persons suffering 
from organic disease of the kidneys, there is danger of poisoning from 
absorption through the intact skin. In children and marantic persons 
it is safer to use acetate of aluminum, salicylic or boric acid, and reserve 
the more potent antiseptics for adults suffering from circumscribed 
inflammatory lesions. Hot fomentations act as derivatives and favor 
the formation of collateral circulation ; at the same time they relieve 
pain. A number of layers of hygroscopic gauze or flannel cloth are 
wrung out of one of these antiseptic solutions and applied over the 
affected part, and for the purpose of retaining the heat and of preventing 
evaporation of the solution the compress is to be covered either with 
gutta-percha, rubber sheeting, or mackintosh cloth, and the dressing is 
retained by an appropriate bandage. The compress is removed two or 
three times a day, again wrung out of the hot solution, and re-applied as 
before. Absorption through the skin of the antiseptic substance used 
may have a direct influence in diminishing the intensity of the cause 
which produced the inflammation, and prepares, in an admirable manner, 
the field for any operation which may become necessaiy later. 

Antipyretics. — If the rise in temperature which attends many of the 
acute inflammatory affections is due to the introduction into the circu- 
lation of phlogistic substances which are produced b}' the action of the 
microorganisms in the inflamed tissues, it is not difficult to conceive that 
its artificial reduction by the internal use of chemical substances is not 
followed by any permanent benefit. The rational treatment of the fever 
consists of such local measures as will remove its cause. Antifebrin, 
antipyrin, salicylated soda, quinine, and other antipyretic drugs, when 
employed in large doses will usually reduce the temperature several 
degrees for a few hours, but this is always accomplished at the expense 
of the forces which are laboring to clear obstructed paths, and on this 
account their use, on the whole, has resulted in more harm than good to 
the patient. Quinine is the least objectionable of the drugs which have 
been mentioned, and in the beginning of an inflammation, by its known 
tonic effect on the small blood-vessels, when administered in a large dose, 
has a favorable effect in preventing rapid dilatation of and stasis within 
the capillary vessels. If used at all, it should be given in a decided 
dose, — 1 gramme, in solution, — immediately or soon after the develop- 



TREATMENT. 139 

ment of the first symptoms. Sponging the surface of the body with 
warm water and the use of warm baths are the most rational antipyretics, 
as these simple measures do not weaken the heart's action, while they 
have a decided effect on the temperature, and at the same time add to 
the comfort of the patient and favor the elimination of microbes through 
the excretory organs of the skin. As the kidneys are known to eliminate 
microorganisms that reach them through the general circulation, their 
function should be carefully inquired into, and if the secretion of the 
urine is scanty, diuretics, like liq. ammon. acet. or acetate of potash, 
should be given. 

Stimulants. — Just as soon as symptoms of sepsis develop in the 
course of an inflammation, alcoholic stimulants should be freely admin- 
istered to meet in time the dangers incident to heart-failure. Stimulants 
have largely taken the place of antiphlogistics at the present time in the 
treatment of septic inflammations. Brandy, cognac, or whisky, not in 
measured doses, but given in quantities large enough to produce the 
desired effect on the heart, are given at intervals of one or two hours. 
Champagne is a more diffusible stimulant, and is to be resorted to when 
the stomach does not tolerate other alcoholics. In chronic cases Tokay 
or Greek sherry is to be preferred. In wasting diseases a good quality 
of beer, ale, or porter will do excellent service. In cases where, from 
any cause, the heart's action is suddenly diminished, strychnine, camphor, 
or musk can be administered subcutaneously to bridge over the time for 
the employment of more substantial stimulants. 

Diet. — The treatment of inflammation by starvation has been abol- 
ished long ago. The strength of the patient must be sustained in time 
by a nutritious, well-selected diet. Animal broths, beef-tea, and milk 
should be freely given from the very beginning, and if more substantial 
food can be digested it should not be withheld. Oysters, eggs, finely- 
scraped raw meat or rare roast are excellent articles of food for patients 
whose strength is being undermined by debilitating, suppurative affec- 
tions. If the stomach does not retain food the patient should be nour- 
ished by rectal enemata of peptonized milk and beef-tea in quantities 
not exceeding 4 ounces, given alternately, every eight hours. Ripe 
oranges and grapes are most always grateful to the patient, and their 
use should never be prohibited, unless the gastro-intestinal canal is the 
seat of inflammation. 

Tonics and Alteratives. — In protracted inflammatory affections tonic 
doses of quinine are indicated. Tincture of chloride of iron is an excel- 
lent remedy after the acute febrile symptoms have subsided. Under 
similar circumstances one or more of the bitter tonics can be given with 
benefit if the appetite is defective. If there is any history of specific 



140 PRINCIPLES OF SURGERY. 

disease, a thorough antisyphilitic treatment will often produce a marked 
effect for the better on the inflammatory process. Catarrhal inflamma- 
tion in rheumatic patients is favorably influenced by antirheumatic rem- 
edies. Syphilitic lesions are to be treated by potassic iodide and small 
doses of corrosive sublimate. Tubercular affections call for guaiacol, 
arseniate of iron, syrup of iodide of iron, and, if the patient's stomach 
can tolerate it, pure codliver-oil. The latter drug should be given alone, 
and not in emulsion, in gradually-increasing doses an hour and a half 
after each meal. 

Anodynes. — Remedies to relieve pain must always be used with 
caution, as in painful chronic affections their prolonged use frequently 
engenders a habit. The cause of pain must be sought for, and, if possible, 
removed by local measures. In acute inflammation pain indicates tension 
in the inflamed part, and prompt relief is obtained by subcutaneous or open 
incision. Periostitis and paron3 T chia should be treated by this method. 
In superficial inflammations scarification answers the same purpose. If 
opiates are used, a decided dose is better than smaller doses frequently 
repeated. The anodyne effect of opium is increased by the addition of a 
minute dose of atropine. Chloral and potassic bromide are to be pre- 
ferred to opium to relieve the pain of intra-cranial lesions. Phenacetin 
in ^-gramme doses is a veiy excellent anodyne in cases of peripheral 
neuritis. Inhalations of chloroform to allay intense pain should never be 
resorted to except by the direction of and under the personal supervision 
of a competent physician. Local applications of anodynes are often 
effective in the treatment of superficial inflammation and neuralgic 
affections. Chloroform liniment and menthol are most frequently 
prescribed for this purpose. 

Massage. — In chronic inflammatory affections systematic massage, 
scientifically practiced, is an exceedingly important and valuable thera- 
peutic resource. It stimulates the surrounding vessels to increased 
action, and exerts a potent influence in restoring the normal circulation 
in the affected capillary vessels, and always promotes absorption. The 
masseur should be instructed to apply some absorbent preparation before 
making the manipulations, as the endermic use of absorbent drugs in this 
manner will increase the efAcac\ T of the treatment. A drachm of potassic 
iodide or half a drachm of iodoform to an ounce of lanolin will be an 
excellent preparation for this purpose. Cold and hot douches, passive 
and active motion, combined with massage, will often expedite a cure. 

Counter-Irritation. — Like so man}' other time-honored methods of 
treatment, counter-irritation in the treatment of acute inflammation has 
almost entirely gone out of use. In chronic inflammation, blistering and 
painting with the tincture of iodine will at least satisfy the patient, if no 



TREATMENT. 141 

good result from them ; and if he do not recover, he is at least prevented 
from passing into the hands of charlatans until the time has arrived to 
resort to more effective and radical measures. Kocher praises the 
application of the actual cautery in the treatment of chronic tubercular 
osteomyelitis and synovitis. The seton and moxa have fallen into 
well-merited disuse for all time to come. 

Ignipuncture. — In many chronic affections, where the inflammatory 
exudation remains stationary for a long time, multiple punctures with 
the needle-point of a Paquelin cautery, made under strict antiseptic pre- 
cautions, will have a prompt effect in mitigating the primary cause, as 
well as in promoting absorption. 



CHAPTER V. 

Pathogenic Bacteria. 

Bacteria, microorganisms, microbes, and germs are synonymous 
terms for certain minute, microscopical, vegetable organisms which, 
when introduced into the living body, produce the fever and the tissue 
changes described in the preceding chapter. For a time it was claimed 
that these minute organisms belonged to the animal kingdom, as some of 
them were seen to possess spontaneous movements ; but now it is gener- 
ally agreed that they are minute plants, and botanists have made great 
progress in perfecting a scientific classification. Among the men who 
have developed this part of botany, the names of Cohn, Zopf, and 
Nageli stand pre-eminent. 

CLASSIFICATION. 

The pathogenic bacteria which will claim our attention belong to 
the class known as schizonoycetes (Spaltpilze). In diameter they vary 
from 0.001 to 0.004 millimetre, and are composed largely of an albu- 
minoid substance called by Nencki myco-protein. Toward the periphery 
this substance becomes firmer, and forms a gelatinous envelope, a sort of 
a membrane, which is said to contain cellulose, and, in some instances, 
even fatty material. The outer surface of bacteria is frequently cov- 
ered with a viscid substance, by which many of them are often held 
together in a mass or group, technically called zooglcea. Each bacterium 
represents a cell, although the presence of a nucleus, or something repre- 
senting such a structure, has not been demonstrated ; but its cellular 
structure is made evident by its intrinsic power of germination or repro- 
duction when surrounded by the necessary conditions for its growth. 
Some of the bacteria are provided with processes, or cilia, by which, 
when suspended in a fluid, movements are accomplished ; in others 
motion is entirely dependent on molecular movements described by 
Brown. Nageli, and formerly Billroth, claimed that all bacteria had a 
common botanical source, and that the different forms and actions only 
represented alteration of form of action of the same plant at different 
stages of development and under different circumstances, — in other words, 
that a coccus could be transformed into a bacillus, and vice versa; and 
that in one instance the same plant caused fermentation, in another 
putrefaction, and that all infective diseases were caused by the same 

(142) 



CLASSIFICATION. 



143 



microbe. Buchner maintained that, by cultivation in different nutrient 
media, he was able to transform the dangerous bacillus of anthrax into 

A 



•••1 
• • • • 



• ••• \ 

• • •• 



*•*»••••• 



A\S 



xs 



o KA'JtfA 









•..• 



*3 



o~ 3 c^ % 7 3 



^ 




j***,*^"*' 



B 



- \. 



1 V V 

V ^** x J 








Fig. 70.— Different Forms of Bacteria. (Baumgarten.) 

A, cocci ; B, bacilli ; C, spirilli. 

the harmless bacillus subtilis, and, again, the latter into the former. 
Cultivation and inoculation experiments on a large scale by most careful 



144 PRINCIPLES OF SURGERY. 

observers have shown conclusively that such transformations never take 
place, and that each microbe not only always retains its shape, but also 
its specific pathogenic properties. Pus- and other microbes have been 
cultivated through thirty and more generations without suffering any 
morphological deviations or losing any of their inherent characteristic 
pathogenic properties. The three principal forms of bacteria discovered 
up to the present time, and which have been demonstrated as causes of 
disease, are: (1) the ball (coccus); (2) rod (bacillus); (3) corkscrew 
(spirillum). As illustrations for these different forms, de Bary very 
appropriately takes the billiard-ball, lead-pencil, and corkscrew. 

The surgeon has to deal only with the first two forms, — the cocci 
and bacilli. Modifications of form are frequently met with, as an oblong- 
coccus closely resembles a short bacillus, and a short, broad bacillus with 
rounded ends approaches the coccus form. Again, a double coccus, or 
diplococcus, with ill-defined constriction at the point of junction, might, 
from superficial examination, be mistaken for a bacillus (Fig. TO, A, 2). 




Fig. 71.— Zooglcea. 



More than two cocci in a row, or a chain of cocci, are called a streptococ- 
cus (A, 3). Four cocci arranged in the form of a square are called a 
micrococcus tetragones (A, 4). Cocci arranged in the form of a bunch 
of grapes are called staphylococci (A, 6). An irregular mass of cocci, 
when at rest and held together by a viscid substance, is described as a 
zooglcea. 

MULTIPLICATION OF BACTERIA. 

Bacteria multipty with great rapidity in tissues presenting favorable 
conditions for their growth, or in proper nutrient media kept at a temper- 
ature approaching that of the bod} r . Multiplication takes place either by 
fissure or segmentation, by the production of spores, or b} T both of these 
methods. The bacillus of anthrax multiplies by fission in the body, by 
spores outside of the body. 

Fission. — The round or globular bacteria, — the cocci, — as far as we 
know, multiply only by fission. The cell elongates prior to segmenta- 
tion, when a constriction appears in the centre, which, by becoming 



MULTIPLICATION OF BACTERIA. 



145 









\ 

8 



( 



s 



deeper and deeper, finally results in complete division of the cell into 
two equal halves, which soon attain the size of the mother-cell, and, in 
turn, again undergo the same process. If the new cells remain adherent 
and arrange themselves in the form of a chain, a streptococcus is formed. 
Fliigge observed complete division of a coccus in bouillon, kept at a tem- 
perature of 35° C, in twenty minutes. If it should require one hour to 
complete segmentation and for the new cell to attain maturity, a single 
coccus multiplying by fission, according to Cohn, during one day, would 
produce sixteen millions of cocci, and at the end of the second day the 
product would represent two hundred and eighty-one billions in number, 
and at the end of three days the extraordinary 
number of forty-seven trillions would be reached. 
Rod bacteria which reproduce themselves by 
fission undergo transverse segmentation in the 
middle, and after complete separation each seg- 
ment grows to the size of the parent-cell before 
the process repeats itself. 

Spores. — The spores of bacteria represent the 
seed of flowering plants. Each spore develops 
into a bacterium, and thus one crop after another 
is produced, the multiplication increasing with 
the number of bacteria in the soil. Most of the 
bacilli multiply by spores. Fructification again 
takes place, either within the protoplasm of the 
cell (endospore) or at one or both extremities of 
the cell (endspore). Fructification is often pre- 
ceded by a rapid elongation of the bacillus. 
Multiple endospores usually form in one bacillus 
simultaneously. The first evidences of the forma- 
tion of spores within the protoplasm of a bacillus 
is indicated by the appearance of circumscribed 
points of cloudiness at equidistant points. 

After the expiration of twenty hours the bacillus appears like a 
string of pearls, each segment of which represents a fully-developed 
spore. After this the segments separate and each spore develops into a 
bacillus. If the bacillus reproduce itself by a single endospore, it does not 
elongate before fructification, but increases in diameter, especially in the 
centre, so that it assumes the shape of a spindle ; while, equidistant 
from its ends, changes are observed in the protoplasm which indicate the 
beginning of spore formation. If the bacillus multiply by terminal 
fructification, one or both of its ends enlarge, become club-shaped, and 
the spores pass through the same stages of development as the endo- 

10 



\ 



Fig 



72. — Endogenous 
Spore Produc- 

tion in Bacillus 
Anthracis Culti- 
vated upon Meat- 
Infusion Peptone- 
Gelatin. X 950. 
{Baumgarten.) 



146 PRINCIPLES OF SURGERY. 

spores, and they are liberated in the same manner, by liquefaction of the 

cell-membrane surrounding them. Bacteriologists are familiar with the 

fact that spores possess a greater power of resistance to germicidal 

agents than the bacilli which produced them. Mature bacteria are alwa}^s 

destroyed by a temperature of 77° C. ; most of them succumb when 

exposed to a heat of 50° to 55° C. On the other hand, some of the 

spores are known to survive a temperature of 100° to 120° C. 

Sternberg has determined the thermal death-point of the following 

bacteria : — 

Fahr. 

Bacillus anthracis (Chaveau), . 129.2° 

Bacillus-anthracis spores, 212.0° 

Bacillus tuberculosis (Schill and Hischer), 212.0° 

Staphylococcus albus, 143.6° 

Staphylococcus pyogenes aureus, 136.4° 

Staphylococcus pyogenes citreus, 143.6° 

Streptococcus erysipelatosus, 129.2° 

Gonococcus, 140.0° 

In all experiments, with the exception of the bacillus of tuberculosis, 
the microbe was subjected to the specified heat for ten minutes ; the 

so m 

,2 3 
Fig. 73.— Spore of Bacillus of Anthrax. X 6-700. (De Bary.) 

S, ripe spore before germination; 1, 2, 3, three successive stages of germinating spore ; 3, young rod. 

tubercle bacillus was destroyed in four minutes. Such resisting spores 
are often not destroyed by boiling continued for several minutes, and 
yield only slowty and frequent^ imperfectly to germicidal chemical 
agents. Surgeons are aware that such spores may remain dormant ill 
the body for years without giving rise to any symptoms until aroused 
to activity by surrounding conditions favorable to their growth and 
development. 

CULTIVATION OF BACTERIA. 

The first cultivation experiments w r ere made with fluid nutrient sub- 
stances, such as bouillon, different animal broths, and solutions of sugar. 
Koch introduced solid nutrient media, which not only serve as food for 
the bacteria, but at the same time present the great advantage that the 
colonies can be seen with the naked eye, and their macroscopical appear- 
ances, as well as the visible action of the bacteria on the nutrient sub- 
stance, often are sufficient to convey reliable information to enable the 
observer to form a positive conclusion in reference to the kind of mi- 
crobes of which the colonies are composed. In fluid nutrient media the 
bacteria cause turbidit} r , or the}' appear as a thin film on the surface ; or 
zooglcea masses show themselves as swimming flocculi ; or, finally, when 



CULTIVATION OF BACTERIA. 147 

the fluid has been exhausted of its nutrient supply the spores settle at 
the bottom of the A^essel and appear as a pulverulent deposit. Upon 
solid nutrient media each kind of bacteria appears as an isolated, dis- 
tinct colony, and as such can be recognized by the naked-eye appearances. 

The substance used first by Koch as a solid medium, and which is 
now used more than any other, was gelatin. Later, a jelly-like sub- 
stance called agar agar, obtained from several sea-weeds on the coasts 
of Japan and India, was found superior to gelatin where a higher than 
ordinary temperature was required to cultivate certain microbes. 
Edington prefers a gelatin made of Irish moss to agar-agar, as it is 
more transparent. Some microbes that will not grow upon gelatin 
vegetate luxuriantly on solid blood-serum. The tubercle bacillus grows 
equally well upon solid blood-serum and glycerin agar-agar. This latter 
substance is easily prepared and is made by adding 6 per cent, of pure 
glycerin to the ordinary agar medium. 

The busy practitioner, who has no time to prepare the media used 
in laboratory work, can do good bacteriological work by using sterilized 
potato or bread-paste. The potato is the best medium for the cultiva- 
tion of chromogenous bacteria, as upon this substance the color is pre- 
served. The potato is scrubbed with a hard brush under a stream of 
water. It is then left in a solution of corrosive sublimate (1 to 1000) 
for an hour or so to disinfect its surface. With a knife rendered sterile 
b}^ passing it through the flame of a Bunsen lamp, a quadrilateral piece 
is cut from the centre, and is rapidly transferred on the knife to a glass 
capsule previously sterilized b}^ heat. Capsule and potato are next 
placed in a steam sterilizer, when the simple apparatus is ready for inocu- 
lation. Inoculation is done by charging the point of an aseptic needle 
with the culture or substance containing the microbes, and after lifting 
the capsule half up a number of streaks are made with the needle upon 
the surface of the potato. A potato-paste, made by adding a sufficient 
quantity of distilled water to the interior portion of boiled potatoes to 
make a paste, is used in the same manner and answers the same purpose 
as sterilized raw potato. 

Bread-paste is made of stale, coarse bread, thoroughly dried in an 
oven, but not roasted. It is pulverized in a clean mortar and the powder 
made into a paste by adding distilled water. The paste is transferred to 
sterile glass capsules and used in the same manner as potato-paste. If 
it is employed for the culture of bacteria, it must be neutralized with a • 
solution of carbonate of soda. Some microbes possess the faculty of 
liquefying the gelatin ; others remain as solid cultures upon the surface 
of the medium, or in its interior. Free access of oxygen to the sent of 
inoculation is essential for the growth of some microbes, and these were 
termed by Pasteur aerobic, while those that germinate with exclusion 



148 



PRINCIPLES OF SURGERY. 



of oxygen he called anaerobic. The former class germinate on the 
surface of the media with or without liquefaction of the soil. If microbes 
of this kind are inoculated by scratching the surface of the medium with 
the point of a needle charged with them, the culture appears first at 
isolated points (Fig. 74, A), which by increase in size become confluent 
and occupy as a solid mass the whole track made by the needle (B, C). 
A microbe which requires oxygen and grows only in the presence of this 
gas is said to be aerobic. A facultative anaeVobic microorganism grows 
and develops either in the presence of oxygen or in its absence. An 
anaerobic microbe cannot grow in the presence of oxygen and, con- 
sequently, grows only below the surface of solid nutrient media. 
Microbes which usually lead a saprophytic existence, but which can also 




Yiq. 74.— Gelatin Cultures following Surface Inoculation. (Flilgge.) 

thrive within the living body, are called facultative parasites. The 
bacillus of lepra is a strict parasite, while the typhoid bacillus, the 
cholera spirillum, etc., are facultative parasites, inasmuch as the}' are 
capable of living and multiplying, under favorable conditions, external to 
the bodies of living animals. 

In making inoculations with anaerobic bacteria the gelatin is 
. punctured with a needle, charged as before, to some depth, and isolated 
colonies appear in the track made by the needle, which by confluence 
form a continuous uninterrupted culture the whole depth of the needle, 
which increases in diameter by extension in a peripheral direction. 
Superficial cultures are called streak cultures ; deep cultures, stab 
cultures. 



ESSENTIAL CONDITION FOR GROWTH OF BACTERIA. 



149 



All cultivation experiments must, of course, be conducted under 
strictest antiseptic precautions, as otherwise there is great danger of 
contamination of the cultures by the accidental ingress of other microbes, 
especially of some forms of fungi. 



ESSENTIAL CONDITION FOR GROWTH OF BACTERIA. 

For the germination of bacteria, besides a proper nutrient substance 
the other conditions which enable the growth of other plants from seed 
are necessary, viz., moisture and a certain degree of heat. Inspissation 
of a solid nutrient medium arrests further development of a culture. 
Bacteria cannot grow upon a perfectly dry medium. Most microbes 
germinate best at a temperature corresponding to blood-heat, but in this 






Fig. 75.— Cultures in Gelatin growing in the Track made by the 

Needle. (Flugge.) 

respect the different kinds show great variance, as some vegetate at 
10° C, while the growth of others will continue at 65° 0. Acids appear 
to produce an inhibitory effect on the process of germination. Laplace 
has utilized this fact and advises the addition of citric acid to solutions 
of corrosive sublimate to intensify its germicidal properties. It is well 
known that the gastric juice suspends the growth of most bacteria. 
Bacteria which live on dead substances exclusively are called sapro- 
phytes. Bacteria which feed on dead substances and can exist in the 
living tissues only at a certain stage of development are called facultative 
parasites, in comparison with the obligatory parasites, which multiply 
exclusively in the living tissues. As representatives of the former can 
be enumerated the bacillus of anthrax and cholera, which, under favor- 



150 PRINCIPLES OF SURGERY. 

able conditions, can multiply outside of the body, while the bacillus of 
tuberculosis germinates only in the living body. 

ACTION OF BACTERIA ON TISSUES OF THE BODY. 

The action of pathogenic bacteria on the tissues is a twofold one. 
In the first place, they abstract from the bod}' a part of its essential 
constituents ; for example, albuminous substances, carbohydrates, oxy- 
gen, etc. These substances are not only taken from the fluids of the 
bod}', as the blood and lymph, but also directly from the protoplasm of 
the cells. In the second place, the}- produce in the body toxic agents 
from their action on the albuminoid substances. The decomposition of 
albuminoid substances by the action of bacteria results in the formation 
of ammonia and its derivatives, the different amines, C0 2 , H 2 S, indol, 
scatol, phenol, asparagin, leucin, ty rosin, etc. 

Ptomaines. — The common names for the toxic substances of bacterial 
origin are ptomaines and toxins. Brieger has isolated a number of pto- 
maines from cultures of different bacteria, and HofTa follows him in the 
same kind of work. Vaughn, of this country, has written a valuable work 
on this subject, which should be read by all who wish to become familiar 
witli modern surgical pathology. Brieger has isolated a number of toxic 
alkaloids, cadaverin, neurin, muscarin, and m} r dalein, which are intensely 
toxic; while the derivatives of ammonia, dimethylamin, trimethylamin, 
and triathylamin, are much less dangerous substances. The ptomaines, 
being soluble substances, are readily absorbed, and when introduced into 
the circulation produce fever and symptoms of sepsis. The toxins 
of the bacillus of tetanus act principally upon the central nervous sys- 
tem, producing characteristic tonic and clonic spasms of definite groups 
of muscles. The ptomaines also produce a definite local effect, — thus, 
the ptomaines of pus-microbes transform the leucocytes and embryonal 
cells into pus-corpuscles, those of the microbe of progressive gangrene 
destroy the protoplasm of the cell-body directly, while the toxic sub- 
stances of the microbes of chronic infected diseases transform the fixed 
tissue-cells into embryonal or granulation cells. Some of the microbes 
remain in the tissue at the seat of infection ; others localize in the 
lymphatic channels ; while, finally, others enter the general circulation 
and multiply in distant organs. The production of ptomaines and toxins 
usualty takes place in the tissues in which localization takes place. 

INOCULATION EXPERIMENTS. 

The mouse, rat, rabbit, guinea-pig, and dog are the animals usually 
selected for this purpose. Inoculations are made either with pure cult- 
ures, which are injected by means of a sterilized l^podermic syringe, 
or infected tissues are implanted under strict antiseptic precautions. 



ATTENUATION OF PATHOGENIC BACTERIA. 151 

Injections of pure cultures are made either into the subcutaneous tissue 
or one of the large serous cavities, the pleural or peritoneal cavit} 7- . The 
same localities are generally selected for inoculation by means of im- 
plantation of infected tissue. For instance, granulation tissue from 
tubercular lesions is either introduced into a small pocket made in the 
subcutaneous tissue in the inguinal region of a guinea-pig, or a small 
fragment is inserted into the pleural or peritoneal cavity through a small 
incision. Before the incision is made it is absolutely necessary to shave 
the surface and disinfect it in the usual way. After the implantation is 
made the wound is closed by suturing with fine catgut, after which it is 
sealed with collodium. In the course of two or three weeks the subcu- 
taneous graft has become the centre of a local tubercular focus, which 
soon gives rise to regional infection through the lymphatic vessels, to be 
followed at the end of five or six weeks by general diffuse miliary tuber- 
culosis. In cases where it is impossible to make a differential diagnosis 
between a syphilitic and tubercular lesion, inoculation of a guinea-pig 
with a fragment of the granulation tissue will furnish positive informa- 
tion in the course of a few weeks. If the lesion is syphilitic, the result 
of the inoculation will be negative; if it is tubercular, local, regional, 
and general infection will follow in regular order. In making implanta- 
tion experiments from animal to animal, it is necessary to remove the 
graft immediately, or soon after death, and to resort to the necessary 
precautions to prevent contamination during its conveyance from the 
dead to the living animal. In bacterial diseases which affect the blood, 
inoculation can be practiced by injecting blood, abstracted from the in- 
fected animal, into the subcutaneous tissue or general circulation of a 
healthy animal, with the effect of reproducing the disease. Anthrax 
and septicaemia of mice furnish good illustrations of this class of 
diseases. 

ATTENUATION OF PATHOGENIC BACTERIA. 

Pasteur opened a wide field for investigation in preventive medicine 
by his introduction of prophylactic inoculations. He experimented first 
with the microbe of chicken-cholera and the bacillus of anthrax. The 
microbe of fowl-cholera was cultivated in chicken bouillon for three, 
four, five, or eight months. He found that by that time the virus 
became so attenuated that, when injected into a healthy chicken, it killed 
only in exceptional cases. Experience showed that attenuation only 
occurred when the culture was freely exposed to atmospheric air, and 
therefore Pasteur believed that the prolonged contact of the culture 
with oxygen diminished its virulence. Chickens inoculated with weak 
cultures were rendered immune to the action of the active virus. The 
same author made the discovery that the anthrax bacillus, cultivated in 
the same way at a temperature ranging between 40° and 43° C, loses its 



152 PRINCIPLES OF SURGERY. 

virulence gradually, so that on the ninth day it is rendered harmless. 
Inoculation with attenuated cultures protected sheep against the active 
virus. Koch, Gaffky, and Loffler found that a culture of anthrax bacilli 
twenty days old, attenuated at a temperature of 42° to 46° C, was still 
sufficiently strong to kill mice, but had little effect on guinea-pigs and 
sheep. A culture twelve days old killed guinea-pigs, but not sheep. It 
proves fatal to sheep up to six days of cultivation. Their views in 
reference to the cause of attenuation differ from Pasteur's, who regards 
oxygen as the active agent, while these observers attribute it exclusively 
to the high temperature. They, like Pasteur, by using attenuated cul- 
tures, succeeded in protecting, in most cases, sheep against the action of 
virulent cultures. In his practical work Pasteur uses two strengths of 
mitigated virus. The milder vaccine is a culture fifteen to twenty days 
old ; the stronger vaccine is from ten to twelve clays old. Sheep are 
inoculated first with the milder vaccine, and after an interval of twelve 
to fifteen days the stronger culture is used. Animals thus treated are 
either entirely immune to anthrax or, if they contract the disease, it 
assumes a mild type. Other methods of attenuation of active cultures 
to be used for prophylactic inoculations have been devised, but, as they 
appear to have been put only to a limited extent to practical tests, they 
will be only briefly mentioned here. Sanderson found that the bacillus 
of anthrax loses much of its virulence when passed through the system 
of a guinea-pig. Toussaint and Chaveau found that the action of a 
temperature of from 50° to 55° C, continued for five to twenty minutes, 
greatly diminishes the virulence of the bacillus of anthrax. For the 
attenuation of spores a temperature of 80° C. is required. 

Paul Bert showed that oxygen, under a pressure of from 20 to 40 
centimetres, destroys the bacillus of anthrax. Toussaint, Chamberland 
and Roux, and Klein made experiments to determine the influence of 
chemical agents in effecting attenuation of active cultures, and their 
work has shown that the virulence of some bacteria can be greatly 
diminished and even entirely suspended by this method of treatment. 
Arloing asserts that anthrax bacilli, exposed to a bright sunlight in a 
liquid medium, gradually part with their toxic qualities. More accurate 
knowledge and greater experience in this interesting field of prophylactic 
inoculations will undoubtedly lead to important results in the near 
future. 

THERAPEUTIC INOCULATION. 

Therapeutic inoculations have been put to a practical test upon a 
knowledge obtained from laboratory work, that direct antagonism exists 
among certain kinds of microorganisms. Emmerich's experiments on 
rabbits have demonstrated the value of the streptococcus of eiysipelas 
as a protective and curative agent in anthrax in these animals. In one 



IMMUNITY. 153 

series of experiments the rabbits were first inoculated with a large 
quantity of a reliable culture of the microbe of erysipelas, and then, two 
to fourteen days later, the animals were infected with a pure culture of 
the anthrax bacillus. Of 15 animals treated in this way 7 recovered, 
while all the control animals inoculated only with anthrax died ; of the 
7 animals which died after double infection, some succumbed to the 
anthrax bacillus and some to the streptococcus of erysipelas. Thera- 
peutic inoculations with cultures of the microbe of erysipelas in animals 
suffering from anthrax were less successful. Garre has studied antag- 
onism among bacteria on culture soils. He made many careful experi- 
ments to determine the growth of a culture on different nutrient media, 
by removal of the entire culture with a minute spade and inoculation 
of the same soil with another microbe. From the results obtained thus 
far he has ascertained that some microbes affect the soil favorabfv for 
the growth of other varieties, while others render it sterile. For ex- 
ample, a culture medium impregnated with the ptomaines of the bacillus 
fluorescens putidus remains perfectly sterile when inoculated with pus- 
microbes. These investigations have an important practical bearing, as 
future research may not only show the way to secure hnnmnity from in- 
fection by pathogenic microbes by prophylactic inoculations with harm- 
less microbes, but may likewise establish a system of rational and 
effective treatment by inoculations of cultures of antagonistic bacteria 
for therapeutic purposes. Therapeutic inoculations with potent cultures 
have also been made with some success in the treatment of inoperable 
malignant tumors. In a recent publication on this subject Brims gives 
the result of 22 cases of malignant growths, including 1 that came under 
his own observation that passed through an attack of erysipelas. Bruns's 
case was one of melanosarcoma of the breast, in which a final cure 
followed the attack. Out of 5 sarcomata 3 were permanently cured, 
'while the other 2 were diminished in size, but soon returned to their 
former size. The effect of the erysipelatous invasion proved negative 
in 6 cases, in which the diagnosis between carcinoma and sarcoma could 
not be positively made, as also in 3 cases of ulcerative epithelioma. It 
is stated that in cicatricial keloid and lymphomata the attack of erysipelas 
proved curative. 

IMMUNITY. 

The antiseptic properties of blood-serum are now generally recog- 
nized. These properties are due to the existence of a substance known 
as globulin, and upon the presence of this substance depends the natural 
immunity of certain animals and persons to some diseases and the im- 
munity artificially produced by the employment of serum obtained from 
immune animals or injections of chemically-prepared antitoxins. Hankin 
thus defines immunity : " Immunity, whether natural or acquired, is due 



154 PRINCIPLES OF SURGERY. 

to the presence of substances which are formed by the metabolism of the 
animal rather than that of the microbe, and which have the power of de- 
stroying the microbes against which immunity is possible or the products 
on which their pathogenic action depends." The clinical observations re- 
lating to the immunity acquired after an attack of certain acute infectious 
diseases and the experimental evidences which have accumulated on the 
same subject tend to support the theory that acquired immunity de- 
pends upon the formation of antitoxins in the bodies of immune persons 
and animals. As secondary factors, it is probable that tolerance to the 
toxic products of pathogenic microbes and phagocytosis are also active, 
but to a lesser extent. 

BACTERIA OUTSIDE OF THE BODY. 

Bacteriology has rendered the term miasma obsolete. All infective 
diseases are now traced to an organic contagium. Most of the bacteria 
are ectogenous ; that is, the}^ exist and, under favorable circumstances, 
multiply outside of the bod}^. The microbe of syphilis, in all probability, 
is an endogenous parasite. Auto-infection is a misapplied term, as nearly 
all, if not all, infective diseases are caused by the introduction into the 
body of pathogenic bacteria from without. Some microbes exist in the 
soil, and as they or their spores may exist in an active condition for an 
indefinite period of time, or even germinate there, they give rise to 
endemics of infective diseases. The anthrax bacillus, the bacillus of 
tetanus, and the actinomyces can be included in this category. Other 
microbes are diffused over large territories through water-courses, as the 
bacillus of typhoid fever and cholera. Finally, some bacteria, like pus- 
microbes, appear to be ubiquitous, being present everywhere and at all 
times. Of all substances which serve as a carrier of microbes, the 
atmospheric air is the most important, because it is present everywhere 
on the surface of the globe, and no one can exclude himself from it. In 
a drjr state, pathogenic bacteria move with the currents of air and attach 
themselves again to the solid or fluid substances with which they come 
in contact. Although most of the pathogenic bacteria under ordinary 
circumstances do not reproduce themselves outside the body, their 
resistance to heat and cold, moisture and dryness, is so great that they 
retain their disease-producing qualities often for an indefinite period of 
time, and after their entrance into the body, and meeting with a proper 
nutrient medium, they exert their specific pathogenic effects. From a 
practical stand-point it is important to remember that infection takes place 
by the entrance into the tissues or body of microorganisms from without, 
through some defect of the skin or mucous membranes ; hence by contact 
entrance of bacteria into the body is effected. As a rule, to which there 



PRESENCE OF PATHOGENIC BACTERIA IN THE HEALTHY BODY. 155 

are few exceptions, bacteria are introduced into the body through a 
wound, abrasion, or ulceration of the skin or a mucous membrane. Such 
a defect or gateway is called an infection-atrium. A healthy, granulating 
surface furnishes almost as secure a protection against infection as the 
skin, but, when the granulations are destroyed or injured, infection is 
again liable to occur. On this account probing of a fistulous canal has 
not infrequently resulted in aggravation of the local symptoms, and 
even in general infection. Kiister reports two cases where patients who 
had undergone an operation for hydrocele by incision, and who were 
'permitted to leave the hospital before the wound had completely healed, 
died subsequently from sepsis caused by careless after-treatment of the 
granulating surface. Most of the microbes, after they have become 
deposited upon an absorbing surface, exercise first their pathogenic 
qualities at the seat of primary localization. The action of some of 
them always remains local. If the infection spread, it does so by dis- 
semination of the microbes over a surface, along the connective tissue, 
or through the lymphatics or blood-vessels. There is no reason to doubt 
that bacteria can gain entrance into the tissues and the circulation by 
passing through intact mucous membranes in the same manner as minute 
particles of inorganic material, like coal-, marble-, and ivory- dust. This 
brings up the question of the 

PRESENCE OF PATHOGENIC BACTERIA IN THE HEALTHY BODY. 

It still remains a disputed question whether pathogenic micro- 
organisms can exist in the body without giving rise to disease. It has 
been definitely ascertained, by experimental research, that many of the 
pathogenic microbes are harmless so long as they remain in the circu- 
lating blood, and that their specific pathogenic action only becomes 
evident after localization has taken place in some part of the body, in a 
soil prepared by injury or disease for their reproduction. It has also 
been conclusively shown, by clinical experience, that pathogenic spores 
may remain in the healthy body, in a dormant condition, for an indefi- 
nite period of time, until, by some accidental pathological changes, the 
tissues in which they may exist have been prepared for their germina- 
tion. Numerous experiments will be cited elsewhere, in which injections 
of pure cultures directly into the circulation produced no ill effects in 
healthy animals, but when, previous to the injection or soon after, an 
injury was inflicted in some part of the body, localization occurred at 
the seat of trauma, and in the locus minoris resistentias thus created the 
microbes produced their specific pathogenic effects. From these remarks 
it is reasonable to assume that pathogenic microbes may and do exist in 
the healthy body without necessarily giving rise to disease, especially if, 



156 PRINCIPLES OF SURGERY. 

as is well known, they are being constantly eliminated through the excre- 
tory organs. 

Bizzozero could not detect bacteria of any kind in animals soon after 
birth, but in the lymph-follicles of the caecum in healthy rabbits he found 
numerous microorganisms. They were seen mostly in the protoplasm 
of cells, — a condition which would indicate that they are transferred from 
the intestinal canal into the closed lymph-follicle through the medium of 
migrating cells. In the human subject Bibbert found microorganisms 
in the interior of the epithelia lining the intestinal canal, but they were 
absent in the submucosa. Perhaps the epithelial cells in this locality 
take the part of phagocytes. Zahor examined the blood, testicle, heart, 
and spleen of a healthy rabbit, and found in fresh, as well as in hardened, 
sections, after staining with methyl-violet, cocci and, here and there, rods. 
The same examinations, with like results, were made on the organs of a 
young cat. Fodor introduced directly into the circulation of rabbits 
pathogenic bacteria, in order to study their effects on the tissues and 
manner of elimination. As a rule, he found they had completely disap- 
peared from the blood after twenty-four hours. He believes that the 
bacteria are destroyed in the circulation by the blood-corpuscles. The 
same author maintains that the power of the blood to destroy bacteria 
is not diminished by a moderate degree of anaemia, but is lessened when 
diluted with water, as, when this is done, the microbes are destroyed 
more slowly and with greater difficulty. The common saprophyte pro- 
teus vulgaris was found to be pathogenic for rabbits when injected into 
the dorsal muscles in sufficient numbers. But, according to the estimates 
made, 225,000,000 were required to cause death, while, with doses of from 
9,000,000 to 112,000,000, a local abscess was produced, and less than 
9,000,000 gave an entirely negative result. Watson-Cheyne found, in his 
experiments made for the purpose of ascertaining the presence of micro- 
organisms in the living tissues, that, while they were not present when 
the animal was in good condition, yet, if the vitality of the animal was 
depressed, say, by administering large doses of phosphorus for some 
time, microbes could be found, at times, in the blood and tissues of the 
body. Again, it has been found that, while some microorganisms, when 
introduced into the living body in small number, disappear after a short 
time, when a large quantity of the culture is introduced the tissues of 
the body are injured b}^ the pre-existing ptomaines, and the microbes re- 
tain their vitality and often cause inflammation of the organ in which 
they locate. The conditions, then, upon which depend the preservation 
of health, in the event of the entrance of pathogenic microbes into the 
body, are: 1. The number of microbes introduced. 2. Absence of a locus 
minoris resistentise. 3. Active elimination through the excretory organs. 






LOCALIZATION OF BACTERIA. 157 

LOCALIZATION OF BACTERIA. 

Every surgeon has had frequent opportunities to observe cases in 
which a slight subcutaneous injury was followed by a destructive inflam- 
mation, — an inflammation not caused by the trauma alone, but by the 
trauma giving rise to localization of pathogenic microbes in the tissues 
altered by the injury. Thus, Chaveau has shown experimentally that 
a subcutaneous contusion furnishes an excellent condition for the locali- 
zation of pathogenic bacteria carried to the part by the circulating 
blood. When he injected a putrid fluid directly into the circulation of 
young rams shortly before crushing subcutaneously one of the testicles, 
the injured organ always became the seat of septic gangrene, while with- 
out such injection the testicle disappeared completely by necrobiosis 
and absorption. Gangrene only occurred if the putrid fluid contained 
bacteria ; it did not take place when the injected fluid had been sterilized 
by filtration. Extensive subcutaneous injuries, as severe contusions, 
rupture of tendons or muscles, and comminuted fractures, are not fol- 
lowed by suppuration unless the injured tissues become subsequently the 
seat of infection with pus-microbes. A patient may have been the sub- 
ject of tubercular infection for an indefinite period of time, and yet may 
present the appearances of ordinary health, until some slight injury 
determines localization of the bacillus in the part injured, — an occur- 
rence which is followed by a localized tuberculosis from which, later, 
regional and general dissemination takes place, to which the patient 
finally succumbs, unless the tubercular focus is removed by an early 
operation. These facts suggest very strongly that, in the hypothetical 
cases, suppuration and tuberculosis would not have occurred in the part 
injured without the injury, and that the injury certainly would not have 
produced suppuration or tuberculosis unless the respective patients had 
been infected previously with specific microorganisms. The injury in 
these cases created a so-called locus minoris resistentise, which may 
signify one of two things: (1) diminution or suspension of the vital 
resistance on the part of the injured tissues to the action of pathogenic 
microbes; or (2) the injury so alters the tissues that bacteria, which 
were present in the circulation without having given rise to symptoms, 
become arrested and find at the same time, at the seat of localization, the 
necessary conditions for their reproduction. Huber studied experi- 
mentally the effect of chemical irritation of tissues in determining locali- 
zation of the bacillus of anthrax. The experiments were made on rabbits, 
in which by the external application of croton-oil to the ear he produced 
a tissue-lesion by the inflammation which followed. One ear was thus 
treated, the other being left in a normal condition in order to compare 
the results of localization of anthrax bacilli in inflamed and normal 



158 PRINCIPLES OF SURGERY. 

vessels. As soon as the inflammation was established, a pure culture 
of anthrax bacilli was inserted subcutaneously at the root of the 
tail ; this place was selected in order to make the infection as far as 
possible from the inflamed ear. In some cases the croton-oil was applied 
after the inoculation. Immediately after the death of the animal, both 
ears were cut off and carefully preserved for subsequent examination, 
and, at the same time, serum and blood were separately taken from the 
inflamed ear and preserved in sterilized glass tubes. 

The results of a number of these experiments enabled the author 
to assert that in all stages of the inflammation the bacilli were never 
found outside the walls of the capillary blood-vessels in the crotonized 
ear. Their number within the blood-vessels depended upon the condition 
of the inflamed vessels. During the first stage of inflammation, marked 
by oedema without suppuration, more bacilli were found within the in- 
flamed vessels than in the corresponding vessels of the opposite ear. 
During the suppurative stage the bacilli disappeared from the vessels. 
During the third stage, when granulations commenced to form, a com- 
plete change was again observed in the bacteriological condition of the 
inflamed part. The height of this stage is reached on the tenth day. 
During this stage the bacilli re-appeared in the inflamed tissue, where 
they could be seen in considerable number, especially in the interior of 
new capillary vessels. During cicatrization the number of bacilli in a 
corresponding area of both ears was about the same. 

From these observations the author concludes that the bacillus of 
anthrax finds, in a soil prepared by inflammation induced with croton-oil, 
a locus mino?Hs resistentise which presents more favorable conditions for 
its localization and growth than the tissues in other parts of the body. 
Suppuration appeared to neutralize the anthracic process by the destruc- 
tive effect of the pus-ptomaines upon the bacilli. 

The conclusions which he has drawn from his experiments may be 
summarized as follows : Localization of pre-existing microorganisms in 
tissues prepared by injury or disease takes place, provided that the 
necessary conditions for their growth are present. In looking over 
different pathological conditions we frequently meet with a so-called 
locus minoris resistentise ; at any rate, if we search only for that which 
should mean what has been described above, it is not difficult to conceive 
how slight injuries, wounds, contusions, etc., should in this manner give 
rise to serious affections. But not only do direct tissue-lesions, as 
haemorrhage, necrosis, li3 7 persemia, fractures, etc., act in this manner, but 
a variety of pathological conditions of a general nature may serve the 
same purpose, as imperfect digestion, enfeebled circulation and respira- 
tion, and particularly irregular distribution of blood resulting from 



LOCALIZATION OF BACTERIA. 159 

exposure to cold. All these ill-defined conditions belong here, and 
through their instrumentalities the localization of infective microbes is 
favored. In secondary or mixed infection the microbes which exist in 
the tissues first prepare the soil for the arrest and germination of other 
bacteria which may reach the circulation. 

Muskatbliith studied experimentally the fate of anthrax bacilli when 
introduced directly into the trachea by injection through the larynx, or 
through a tracheotomy wound. From the results which he obtained he 
concludes that the bacilli can enter the circulation through the bronchial 
mucous membrane, and that the juice-canals and lymphatics are the 
channels through which the infection takes place. It appeared strange 
to the author that no bacilli could be found in leucocytes, but always 
only in epithelial cells. Final localization of the bacilli which have 
entered the circulation through the lungs takes place in distant organs 
by implantation upon the endothelial lining of the capillar}^ vessels. 

Other experimenters affirm that if the anthrax bacilli are injected in 
moderate quantities into the circulation of animals, they disappear soon 
from the blood without having produced any pathogenic effects ; but, if 
in animals thus infected a contusion is produced in some part of the 
body, the bacilli pass out of the injured vessels into the connective tissue 
along with the blood, germinate there, and soon cause the formation of 
the characteristic inflammatory product, the disease becomes diffused, 
and the animals die of anthrax. Localization of the bacillus of tubercu- 
losis affords an interesting subject for experimental research and clinical 
study. 

The late distinguished Professor von Yolkmann, from an extensive 
clinical experience, came long ago to the important and practical con- 
clusion that a severe trauma seldom, if ever, gives rise to tuberculosis 
at the seat of injury; and, on the other hand, that in cases where tuber- 
culosis develops in consequence of any injury, the trauma is alwa} T s 
slight, sometimes almost insignificant. The experience of almost every 
surgeon will agree with these statements. Volkmann maintains that the 
active tissue changes which follow a severe trauma during the reparative 
process counteract the growth and propagation of the bacillus. Luecke 
attributes to exposure to cold an important role in the causation of 
tubercular and other infective forms of inflammation, as he asserts that 
the sudden diminution of blood-supply to the cutaneous surface causes 
internal congestions, which favor the localization of pathogenic microbes 
in some one of the congested organs, otherwise predisposed to the specific 
inflammation. Schiiller studied the localization of the tubercular virus 
experimentally in the same manner as others have studied the locali- 
zation of pus-microbes. He inoculated animals with the products of 



160 PRINCIPLES OF SURGERY. 

tubercular inflammation, subsequently produced contusions and sprains 
of joints, and observed that localization usually occurred at the seat of 
injury. If the tubercular virus was introduced b} r inhalation, the same 
typical lesions occurred in the injured joints as when infection was prac- 
ticed in a more direct manner. In all cases the product of the local 
joint-lesion corresponded with the character of the material introduced 
through some remote point. Surgeons are well aware of the danger of 
general infection following an injury to a part or an organ the seat of 
local tuberculosis, more particularly in cases of tubercular disease of 
joints treated by brisement force. Numerous cases are recorded where 
this procedure was followed within a few days b}- general miliary tuber- 
culosis and a speedy death. In all cases where a local tuberculosis 
develops in consequence of an injury, we must take it for granted that 
the injured part contained the essential cause of the disease, the bacillus 
of Koch, and that the lesions caused by the trauma created the necessary 
conditions for its reproduction; or, if the injured tissues at the time are 
sterile, that they serve the purpose of a locus minoris resistentiee for 
bacilli which might reach them through the circulation. The frequency 
with which suppuration occurs without any visible infection-atrium has 
led bacteriologists to investigate with special care and diligence localiza- 
tion of pus-microbes. 

Rosenbach ascertained, \)j numerous experiments, that acute suppu- 
rative osteomyelitis could only be produced by injecting pus-microbes 
directly into the circulation and by injuring the medullary tissue a few 
days before or after the inoculation. Kocher, Becker, and Krause 
repeated the experiments of Rosenbach, and came essentially to the 
same conclusions. Both Kocher and Rosenbach look upon the altered 
circulation in the injured part as the essential condition which determines 
localization of the pus-microbes floating in the blood-current ; at the 
same time t\\ey admit that the immediate tissue-lesions, haemorrhage, 
and necrosis may have the same effect. Upon the same theory, Kocher 
explains the occurrence of traumatic suppurative strumitis in a lrrper- 
plastic struma. If non-septic pus is injected into the circulation of 
healthy animals in moderate quantities no serious results are produced, 
as the pus-microbes are soon eliminated through the kidnej^s. If, how- 
ever, the pus-microbes attach themselves in the circulation to some 
foreign substance which prevents such elimination, suppuration will 
follow. A number of experiments made, among others hy Ribbert, on 
the production of nrvo- and endo- carditis in rabbits, have shown that 
abscesses can be produced in other organs if the p}'ogenic microbes are 
attached to foreign bodies which cannot pass through the pulmonary 
capillaries. Thus, Ribbert was able to produce nrvocarditis by using a 



i 



LOCALIZATION OF BACTERIA. 161 

cultivation of staphylococcus pyogenes aureus on potato, if he took the 
precaution, in removing the culture from the surface of the potato, to 
scrape off also the superficial surface of the potato itself. The particles 
of potato injected with the microbes determined suppuration by causing 
localization of the microbes, as the foreign bodies were too large to pass 
through the capillary vessels and were not capable of removal by 
absorption. 

The influence of a trauma in determining localization of microbes 
circulating in the blood is well shown by the experiments which have 
been made to produce, artificially, endocarditis in animals. 0. Rosen- 
bach made the first experiments of this kind. He observed, in his 
experiments on animals and in post-mortem examinations in cases of 
ulcerative endocarditis, microbic emboli in the valves of the heart and in 
the infarcts of other organs, and classifies this affection with pj^semia. 
The more frequent occurrence of endocarditis in the left side of the 
heart than the right he explains by assuming that the microbes find a 
better soil in the arterial blood, as when the affection occurs in the foetus 
during intra-uterine life, when the blood in both sides of the heart is of 
about the same composition, the valves in both sides are affected with 
the same frequenc}^ Orth and Wy ssokowitsch found that stapl^lococci 
could be injected into the blood of a rabbit without apparent injury to 
it, but if before the injection a slight mechanical injury was inflicted on 
one of the valves of the heart, typical endocarditis was at once produced. 
The injury was produced with a small rod, which was introduced into 
the jugular vein on the right side. The endocardial lesion always 
corresponded to the sent of the injury. Similar results were obtained 
by Frankel and Sanger. 

Rhine came to different conclusions in reference to injured tissues 

serving as a locus minoris resistentise in the causation of inflammation 

due to the presence of microbes. He injected pure cultures of the 

different kinds of pus-microbes directly into the circulation of animals, 

and found that, as a rule, no harm resulted. In rabbits he injected from 

2 to 3 Pravaz syringefuls of unfiltered, distilled water, holding in 

suspension pure cultures, and, after repeating this dose several times, 

inflicted all kinds of subcutaneous lesions without causing suppuration. 

Only in a few instances were pysemic metastases observed, and these 

occurred usually onty in cases where undiluted gelatin cultures were 

used. In several dogs he made subcutaneous fractures and then injected 

large doses of cultures of pus-microbes, suspended in distilled water, 

into the peritoneal cavity, but no suppuration occurred at the seat of 

trauma. In six rabbits he fractured the femur subcutaneously and then 

injected pure cultures into the jugular, or one of the auricular, veins, but 

li 



162 PRINCIPLES OF SURGERY. 

only in one of them did osteomyelitis occur at the seat of fracture. In 
two experiments where he injected osteonryelitic pus diluted with 
distilled water the seat of fracture suppurated, and in these cases 
abscesses were also found in the heart-muscle and the kidnej^s at the 
autopsy. It is difficult to explain the discrepancy between the results 
obtained by Rhine and the other experimenters who have been quoted, 
as the same kind of animals and inoculation material were used, and the 
experiments were conducted in the same manner. The fact remains, 
and is abundantly vouched for by clinical experience, that a subcutaneous 
injury, if the tissues remain sterile, does not give rise to inflammation, 
and that many inflammatory processes are established immediately or soon 
after an injury, and in the inflammatory product the presence of patho- 
genic bacteria can be demonstrated by microscopical examination, cultiva- 
tion, and inoculation experiments. A number of well-authenticated cases 
of osteomyelitis after simple subcutaneous fracture have been recorded 
where the infection could be traced to a slight peripheral suppurative 
lesion. The same can be said of many cases of suppurative osteo- 
myelitis which occur without fracture, where the exciting cause can be 
referred to some slight injury, or exposure to cold, and the essential 
cause can be located in some pus-producing lesion in a distant part, and 
having no direct vascular connections with the suppurating medullary 
tissue. From a scientific and practical stand-point, it is important to 
recognize the existence of local conditions in the tissues created by a 
trauma, or antecedent pathological conditions, to explain the localization 
of floating microbes and the production of local affections by their 
uniform presence and constant pathogenic action. 

SECONDARY OR MIXED INFECTION. 

Antecedent pathological products may serve the same purpose in 
the body as a trauma in the determination of localization of pathogenic 
microbes. Suppuration in a tumor, or a hyperplastic gland with an 
intact cutaneous covering, indicates that in the tumor or swelling pus- 
microbes have been arrested, and that they have been deposited in a soil 
adapted to their germination and the exercise of their pathogenic 
qualities. The atypical vascularization in tumors and the partial 
obstruction in the lumen of blood-vessels in inflammatory swellings 
cannot fail in creating conditions which determine nitration of bacteria- 
containing blood. If the pre-existing pathological product is the result 
of a previous infection, and serves as a medium for localization of another 
kind of pathogenic microbes, we speak of the combined process due to 
the presence of two varieties of microorganisms as a mixed infection. 
The first positive proof of the existence of a secondary or mixed in fee- 



SECONDARY OR MIXED INFECTION. 163 

tion was furnished by Brieger and Ehrlicb. These observers saw a 
malignant oedema develop at the point where musk was injected hypo- 
dermatically in a severe case of typhoid fever. They found that in 
such cases a predisposition is established by an existing disease to the 
growth and reproduction of microorganisms, which may have been 
previously present in the organism without producing any pathological 
lesions. 

Koch, in his article on " The Etiology of Tuberculosis," alludes to 
the occurrence of mixed infection, as he states that he saw at the same 
time bacilli and micrococci present in the same tubercular lesion. In 
reference to the occurrence of micrococci in tubercular deposits in the 
lungs and spleen, he explained their presence upon the supposition that 
they entered the circulation through ulcerations of the tongue, and that 
they became arrested in the capillary vessels, which had lost their normal 
resisting power by the tubercular process. Bumm maintains that in 
some patients secondary infection is a purely accidental occurrence, as, 
for example, a tuberculous patient can be attacked with erysipelas ; a 
lying-in woman suffering from gonorrhoea may become the subject of 
septic infection. 

Another and practically more important variety of mixed infection 
he speaks of where a more direct relation exists between the different 
microbes, in the sense that the one precedes the other and prepares the 
soil for the growth of the latter. These forms are characterized by 
being constantly associated with certain definite microbes. The pneu- 
mococcus may prepare the soil for fructification of the bacillus of tuber- 
culosis or the microbes of suppuration in individuals that otherwise 
would have been immune to the action of these microorganisms. The 
gonococcus can also modify the mucous membrane of the genito-urinaiy 
tract in such a manner as to render eas}^ the invasion of other pathogenic 
microbes. Gonorrhceal infection of the A r ulvo-vaginal gland furnishes a 
good illustration. As long as the infection remains purely gonorrhceal, 
the acute suppurative stage is followed b}^ a chronic stage which may 
last for several months, the swelling gradually subsides, and subsequently 
atroplry and sclerosis of the gland follow. If, however, purulent infec- 
tion is added to the gonorrhoea, the gland soon becomes enlarged and 
tender, and suppuration follows. In the abscess and its vicinit}^ no 
gonococci can be found; the pus only contains p} r ogenic microbes, which 
exterminated the gonococci. Cystitis which accompanies gonorrhoea is, 
again, a variety of mixed infection. The stratified epithelium of the 
bladder is impenetrable to the gonococcus. 

According to Bumm the c} T stitis is maintained by another species 
of microbe resembling the gonococcus, but differing from it by taking a 



164 PRINCIPLES OF SURGERY. 

different staining. The gonococeus expends its action on the superficial 
layers of the mucous membrane exclusively. Suppurative parametritis 
following gonorrhoea is analogous to a gonorrhoeic bubo, which is always 
caused by a secondary infection with pus-microbes. A valuable contri- 
bution to our knowledge of mixed infection has recently been made by 
Babes. His investigations consist of a series of bacteriological studies 
of the tissues of children who died of infectious diseases. Within a 
few hours after death fragments of tissue were removed from different 
organs which, under strict antiseptic precautions, were imbedded in 
sterilized culture material. In acute infectious diseases, such as diph- 
theria and scarlatina, cultures from the spleen, kidne} r s, liver, lungs, and 
blood yielded numerous colonies of streptococci, putrefactive bacteria, 
capsule cocci, more rarely staplrylococci and various bacilli. Of special 
interest are his researches on the manner of localization and extension 
of the secondary invasion after different primary diseases. In 8 cadavers 
he found one or more species of bacteria in the internal organs. In a 
case of septic omphalitis he found the bacillus of green pus. In 6 cases 
of different forms of infectious disease the streptococcus pyogenes could 
be cultivated from the tissues, and only in 1 was the } T ellow pus-microbe 
present in the culture. Various putrefactive bacilli were cultivated from 
5 cases. In some instances he was able to demonstrate the point at 
which the different secondary invasions had taken place. Thus, in a case 
of sepsis after scarlatina, in which streptococci were found in every part 
of the body, a streptococcus pneumoniae was found in the lower portion 
of the left lung, while a number of foci in the upper portion of the 
opposite lung contained only bacilli. 

Frankel and Freudenberg cultivated from internal organs of 3 patients 
who had died of scarlatina the streptococcus p3'ogenes, and the} T maintain 
that the presence of this microbe is evidence that a secondary infection 
takes place through the diseased mucous membrane of the pharynx. 

Schnitzler, after having observed and carefully studied a number of 
cases, has come to the conclusion that syphilitic ulcerations of the larynx 
may pass into tubercular, as the S3 T philitic ulcer furnishes a good culture 
soil for the bacillus of tuberculosis. 

Hiiber attributes the occurrence of suppuration and gangrene in 
croupous pneumonia, phlegmonous inflammation and suppuration in ery- 
sipelas, and suppuration in tubercular processes to secondary infection 
with pus-microbes. As the bacillus of tuberculosis and the streptococcus 
of erysipelas do not possess the propert}' of converting leucocytes and 
embryonal cells into pus-corpuscles, suppuration, if it does occur in these 
diseases, can only be accounted for by admitting the existence of a 
secondary infection with pus-microbes. 



ELIMINATION OF PATHOGENIC BACTERIA. 165 

The important question presents itself whether, in cases of mixed 
infection, the two or more kinds of microbes enter the organism at the 
same time, or whether primary infection prepares the way for the en- 
trance and fructification of the microbes which produce the secondarj 7 
infection. Pus-microbes being present at all times and everywhere, and 
perhaps gaining entrance into the body more readily than others, it is 
very eas} 7 to understand why secondary infection b} - them is most fre- 
quently observed. Rosenbach frequently found in pus more than one 
kind of pyogenic microbes. He often cultivated from the same pus two 
kinds of staphylococci, or one variety of staphylococci with streptococci. 
While antagonism among some bacteria has been shown to exist, others 
prepare the soil for the growth of a different variety, and in such in- 
stances it is not difficult to conceive that secondary infection is of fre- 
quent occurrence. For instance, any microbe that will convert mature 
tissue into embryonal cells abbreviates and lightens the work of pus- 
microbes in converting fixed tissue-cells into pus-corpuscles. 

ELIMINATION OF PATHOGENIC BACTERIA. 

Having described the different wajs in which pathogenic bacteria 
enter the body, it now remains to show in what manner they are disposed 
of in the event no harm follows, or the patient recovers from the disease 
which the} 7 produced. The probable existence of disease-producing 
microorganisms in the healthy body and the spontaneous subsidence of 
many infective processes make it important to consider the waj T s and 
means by which the} 7 are rendered harmless in the living body, or are 
removed by elimination through some of the excretory organs. In all 
infective processes in which life is not destroyed, and the products of 
inflammation do not find their way to the surface spontaneously or by 
operative treatment, the microbes are either destroyed in the blood and 
the tissues by phagoc} 7 tosis or are eliminated through some of the excre- 
tory organs in an active state. The rapid disappearance of most microbes 
from the blood when injected into the circulation of healthy animals 
would indicate that an active warfare is instituted against them b} 7 the 
colored corpuscles of the blood, in which the microbes are defeated, — 
that is, destroyed. If some of the microbes pass through the capillary 
blood-vessels and come in direct contact with the fixed tissue-cells, a 
similar struggle ensues between them and the tissue-cells, and if the latter 
are victorious the microbes are destined. Successful phagocytosis must 
therefore be considered as the most efficient and desirable way of dispos- 
ing of pathogenic bacteria after the} 7 have entered the tissues or the 
general circulation. But should phagocytosis prove unsuccessful in de- 
stroying the microbes which have reached the blood, there is still another 



166 PRINCIPLES OF SURGERY. 

way in which the unassisted resources of the organism can deal with 
them successfully, viz., elimination through one or more of the excretory 
organs. The critical discharges of the ancient authors — profuse sweat- 
ing, diarrhoea, and copious secretion of urine — in the light of modern 
science have received a different significance, as they are now regarded 
as efforts of the vis medicatr*ix naturae to throw off the cause which pro- 
duced the disease, — the pathogenic microbes and their ptomaines. The 
kidneys and the mucous membrane of the intestinal canal are the organs 
most concerned in the process of elimination. That microbes in an 
active state are eliminated by the kidneys is shown by various observa- 
tions, and this is an important point to remember as probably explain- 
ing certain cases of pyelitis occurring in patients who have never had 
any instrument passed, and in whom the urethra and bladder are perfectly 
normal. The salivary glands, more especially the parotid, occasionally 
take part in the elimination of pus-microbes, thus offering an explanation 
of the not infrequent occurrence of abscesses in this gland after suppura- 
tion elsewhere. The frequency with which the kidneys are affected in 
cases of tuberculosis furnishes an evidence that elimination of bacilli 
takes place through these organs. Philipowicz produced tuberculosis in 
animals by injecting urine taken from tubercular subjects into the peri- 
toneal cavity. Neumann found the specific microbes in the urine in cases 
of typhus, septicaemia, and pyaemia. In a case of acute endocarditis and 
osteomyelitis he cultivated from the urine the staplrylococcus pyogenes 
aureus. He asserts that the microorganisms which circulate in the 
blood localize in the capillary vessels of the kidney, where they often 
cause minute multiple lesions without implication of the entire paren- 
chyma of the organ. Through the altered tissues some of the microbes 
enter the tubuli uriniferi, and are washed away with the urine. Philip- 
owicz found bacilli in the urine in anthrax and glanders. Schweiger 
has shown conclusively, by his bacteriological researches, that the urine 
from scarlatinal patients is contagious ; for varicella, typhus recurrens, 
and malaria the same holds true. Schweiger regards all kidney-lesions 
occurring in the course of infective diseases of microbic origin. To 
prove that microbes pass through the kidneys, he cultivated a bacillus 
which Reimann discovered in the pus of ozrena. This bacillus is stained 
an intense green color in a culture of gelatin and agar after twenty-four 
hours. A culture of this bacillus was diluted with a physiological solu- 
tion of salt and injected directly into the circulation. The experiments 
were made on a dog, cat, and rabbit. A certain length of time inter- 
vened between the injection and the appearance of bacilli in the urine, 
as though, somewhere on their way, an obstacle had been met with. At 
first only isolated bacilli were found in the urine, but later on they 



DIRECT TRANSMISSION OF PATHOGENIC BACTERIA. 167 

appeared in larger numbers. Bacteriological examinations of milk have 
shown that different kinds of pathogenic bacteria are eliminated through 
the mammary gland. Yon Eiselsberg demonstrated by cultivation 
experiments the presence of staplrylococcus pj r ogenes aureus in the 
sweat of a pysemic patient, and after death he found the same microbe in 
the blood of different organs. The chapter on Bacteria would not be 
complete without at least alluding briefly to what is known in refer- 
ence to 

DIRECT TRANSMISSION OF PATHOGENIC BACTERIA FROM 
PARENTS TO FCETUS. 

That many of the infectious surgical diseases are hereditary has 
been admitted by the best authorities for a long time, and many theories 
have been advanced to explain their transmission from parents to child. 
The modern views on this subject may be narrowed down to two suppo- 
sitions : 1. Transmission from parents to child of a predisposition to 
certain diseases. 2. Direct transmission from parents to foetus of the 
essential cause of the disease. The supposed hereditary predisposition 
is interpreted as meaning some congenital anatomical or physiological 
defects in the tissues, which render the organism unduly susceptible to 
the action of post-natal microbic infection. The existence of minute 
anatomical defects of blood-vessels, lymphatic vessels and glands, con- 
nective-tissue spaces, etc., has been advanced in explanation of a greater 
liability of infection with floating microbes, which enter the circulation 
after birth. 

An inherited defective vital resistance on the part of the tissues to 
the action of bacteria is also considered by many in the light of a con- 
genital influence in the causation of disease. The above-mentioned 
conditions are recognized, but no satisfactory, demonstrative, or experi- 
mental proofs of their existence have as yet been furnished, and yet the 
immunity of some animals to certain diseases cannot be explained in any 
other way than in attributing to the tissues anatomical or pl^siological 
properties which protect the organism against the action of certain 
microorganisms which, in other animals not so protected b}^ inherited 
qualities, produce a serious or fatal disease. Clinical observation also 
teaches us that a great difference exists among different persons in refer- 
ence to the degree of susceptibilit}^ to the same form of infection. In 
many persons, for instance, inoculation with a pure culture of tubercle 
bacilli would be a perfectly harmless procedure ; in some it would be 
followed by a localized tubercular process which, in the course of time, 
might heal spontaneously; while in a few, rendered more susceptible to 
this form of infection by hereditary or acquired causes, inoculation with 



168 PRINCIPLES OF SURGERY. 

the same number of bacilli would be followed by a severe form of local 
tuberculosis, soon to be followed by regional and general dissemination 
and death. The same can be said of nearly all, if not all, infectious 
diseases. If their existence has not been demonstrated, we are, neverthe- 
less, forced to accept the influence of certain as yet unknown conditions 
inherent in the tissues, and which are often traceable to a congenital cause 
or causes which favor or resist post-natal microbic diseases. During the 
last few years some progress has been made in showing that hereditary 
diseases, in many instances at least, are due to a more direct cause, — 
transmission from parents to foetus of the essential cause of the disease, — 
pathogenic microbes. Although our knowledge of the intra-uterine 
origin of microbic diseases is as yet imperfect, there can be no doubt 
that future stud}' - and research will clear up many dark points and fur- 
nish satisfactory demonstrative explanations of the direct and indirect 
hereditaiy influences in the causation of disease. It is well known that 
small-pox, measles, and scarlatina are directly transmissible from mother 
to foetus. Numerous well-authenticated cases of these diseases occur- 
ring in newborn children have been recorded. Lebedeff reports a case 
of premature birth which occurred eight da} r s after the mother had 
recovered from erj-sipelas. The child died ten minutes after birth, and 
the author found Fehleisen's streptococcus in the tyinphatic vessels, in 
the diseased skin, and in the umbilical cord, but none in the placenta. 
The author believes that the streptococci were transported from the 
Pymphatic vessels of the lower extremities of the mother through the 
lymphatics of the uterus into the placental vessels, and from the maternal 
into the foetal circulation. Ahlfeld and Marchand report the case of 
a woman who presented no symptoms of disease except a moderate 
pallor and t3'mpanitic distention of the abdomen. After a normal labor 
she gave birth to her second child ; eight hours after delivery the patient 
died in collapse, for which no cause could be found. The autops}- re- 
vealed anthrax as the cause of death. The child died four days after 
birth, from the same cause. The mother, as was later ascertained, con- 
tracted the disease in sorting horse-hair, and the child was infected 
directty through the placental circulation. Sangalli found the bacilli of 
anthrax in the blood of a foetus from a woman who had died of anthrax. 
In opposition to Golzi and others, he affirms that the transmission of 
the disease from mother to foetus could only have taken place \>y the 
passage of the bacilli or spores from the maternal to the foetal circulation 
through the placental vessels. Netter reports a carefull3 r -observed case 
of direct transmission of the diplococcus of pneumonia from mother to 
foetus. The mother was a Vl-para, pregnant eight months, when she was 
attacked with croupous pneumonia, which terminated on the seventh day 



DIRECT TRANSMISSION OF PATHOGENIC BACTERIA. 169 

in recovery. On the ninth clay after the attack she was delivered of a 
living child. The child died on the fifth day after birth. The autopsy 
revealed lobar pneumonia involving the right upper lobe, double fibrinous 
pleuritis, pericarditis, suppurative meningitis, and otitis media on both 
sides. Bacteriological examination of the different inflammatory products, 
as well as of the blood taken from the left ventricle, showed the presence 
of Frankel's diplococcus pneumoniae. One of the strongest evidences 
of direct transmission of pathogenic microbes from mother to foetus 
through the placental circulation is the often-quoted observation made 
b} r Johne. An eight months' foetus w r as taken from a cow the subject 
of advanced tuberculosis. No tuberculous products were found in the 
placenta or the uterus, but in the lower lobe of the right lung of the 
foetus a nodule the size of a pea was detected, containing four caseous 
centres. The bronchial glands were tubercular. The liver contained 
numerous miliary nodules. All the lesions presented, under the micro- 
scope, the characteristic histological structure of tubercle. Jani has 
examined the healthy sexual organs of nine phthisical patients for 
tubercle bacilli. No bacilli were found, in any of these, in the semen 
from the vesiculse seminalis, but, on the other hand, in 5 out of 8 cases, 
a few were found in the testicle, and in 4 out of 6 in the prostate gland. 
He further examined two women who died of pulmonary phthisis, the 
ovaries in both presenting negative results. In one case of chronic 
pulmonar}^ phthisis, with extensive intestinal tuberculosis, he examined 
the Fallopian tubes, and found tubercle bacilli. He believes that the 
tuberculous virus can be transmitted from parents to offspring in one of 
two ways : 1. Through the semen of the male. 2. Through the migration 
of bacilli into the uterus from the abdominal cavity. The frequency with 
which the Fallopian tubes are the seat of tuberculous lesions makes it 
more than probable that the ovum, on its way from the ovaries to the 
uterine cavity, is infected with bacilli. It also requires no stretch of the 
imagination to understand how the spermatozoa in the testicle or on its 
way to the vesiculse seminalis can be contaminated with bacilli, and thus 
the disease directly transmitted from father to foetus. 

That S} T philis is a microbic disease can no longer be doubted, and 
that it is one of the diseases which is most frequentPy transmitted from 
parents to offspring is well known. 

That pathogenic microorganisms may exist in the blood of ap- 
parentty healthy mothers without doing any harm is well illustrated by 
children who have been born suffering from suppurative osteomyelitis, 
while the mothers, through whose blood only the microorganisms could 
have come, showed no evidences of disease. Kosenbach reports such a 
case in his article on acute osteomyelitis. Transmission of microbic 



170 PRINCIPLES OF SURGERY. 

diseases through the placental circulation has been made the subject 
of experimental inquiry. Strauss and Chamberland experimented on 
guinea-pigs to prove that intra-uterine transmission of anthrax from 
mother to offspring is possible. <jravid animals were inoculated with 
the virus of anthrax, and the foetuses examined immediately after death. 
Blood taken from the cavities of the heart and liver, examined under the 
microscope, never showed bacilli. Cultivation experiments were made 
with the foetal blood in veal-bouillon, and these proved that in some 
instances the blood of all foetuses from the same mother contained 
bacilli ; sometimes from the same litter all cultures remained sterile, 
while in some the blood of only one foetus would yield a positive result. 
From these experiments the authors came to the conclusion that the 
tissues of the placenta offer no insurmountable obstacle to the passage 
of the bacillus of anthrax from the maternal into the foetal circulation. 
Koubassotf came to more positive results in his experiments. In all of 
his experiments the foetuses of the infected animals contracted the dis- 
ease in utero. He also found that time phvyed an important role as far 
as the number of bacilli in the foetus was concerned, as, the longer the 
period which intervened between the inoculation and the death of the 
mother, the more numerous were the bacilli in the foetal organs, showing 
that the migration of microbes from the maternal to the foetal side of the 
placenta is continuous. Inoculation with attenuated virus proved that 
intra-uterine transmission took place more slowly. Inoculation of gravid 
animals with a very strong culture nearly always proved fatal to the 
foetuses. Most all authors agree that, when extravasations or other patho- 
logical processes occur in the placental attachment, the direct entrance 
of microbes from the maternal into the foetal circulation is not only pos- 
sible, but a probable occurrence. Abnormality of the placental circu- 
lation must, therefore, be recognized as a condition which favors the 
occurrence of hereditary microbic disease. Both clinical observation and 
experimental research leave no room for doubt that in some infectious 
diseases, at least, heredity is traceable to direct transmission of the specific 
microbes, either by means of transportation by the spermatozoa to the ovum 
or by their entrance through the thin wall which separates the maternal 
from the foetal circulation. It is no more difficult to explain the mi- 
gration of microbes through such a thin septum than their transporta- 
tion from one tissue to another and from organ to organ in other parts 
of the body, more especially as the anatomical conditions for mural 
implantation in the placental vessels are most favorable for such an 
occurrence. 



CHAPTER VI. 

Necrosis. 

Necrosis, gangrene, mortification, and sphacelus are terms used 
synonymously to indicate the death of a part. English and American 
writers have usually restricted the meaning of the word necrosis to death 
of bone, while the remaining terms were used to express the same con- 
dition affecting the soft tissues. Recently a sharp distinction has been 
made between necrosis and gangrene from an etiological stand-point, 
according to which necrosis is said to have taken place when the circu- 
lation and nutritive changes in a part have completely ceased to be 
followed by gangrene as soon as saprophytic bacteria invade it and give 
rise to putrefaction. Death of bone will never be described as gangrene, 
and the moist putrefactive form of gangrene of the soft tissues will, in 
all probability, be never designated by the term necrosis. Necrosis of 
bone takes place in the same manner and results from the same causes 
as gangrene of the soft parts, and on this account there does not appear 
to be sufficient reasons to apply different terms to identical processes 
occurring in different anatomical structures; and yet by long usage they 
have become so intimately associated with the anatomical character of 
the part affected that it is difficult, for the present at least, to drop 
either. In modern literature we speak of necrosis of the soft tissues 
when the dead structures do not undergo putrefaction ; that is, when this 
process takes place in the internal organs not readily accessible to 
putrefactive bacteria, or when it involves external parts and is unat- 
tended by putrefaction. In its extent necrosis varies greatly ; it ma}' 
involve an entire limb, an entire organ, or may be limited to a single cell. 
As a physiological process it occurs everywhere in the tissues, being 
limited, however, to individual cells incident to the wear and tear of the 
bod}', the pulling down and building up of the tissues, the cells that are 
lost being replaced by the normal process of regeneration. A simple, 
numerically increased cell necrosis, without normal restitution, leads to 
atrophy, — necrosis atrophica. When all the cells of a part undergo death 
simultaneously, the circulation corresponding to the area of dead tissue 
is arrested completely, and with this absolute ischaemia, plasma circula- 
tion, and all functions are, of course, complete^ suspended, — a serious 
pathological condition. A total necrosis has occurred. 

(171) 



172 PRINCIPLES OF SURGERY. 

ETIOLOGY. 

Necrosis is a condition, not a disease. As a symptom it represents 
a local condition which has been brought about by different causes. The 
most frequent causes of necrosis are the following : — 

Inflammation. — Inflammation may produce necrosis in two different 
ways : 1. Exudation and transudation take place so rapidly that com- 
plete stasis is produced by the extra-vascular pressure. 2. The bacterial 
cause of the inflammation is present in such large quantities that the 
vitality of the tissue is destroyed directly from this cause. If during 
an acute inflammation the capillary walls undergo such serious alteration 
that within a few hours or days the connective-tissue spaces become so 
densely packed with the corpuscular elements of the blood that the 
plasma circulation is greatly impeded or completely arrested, the primary 
inflammatory product encroaches upon the capillary vessels to such an 
extent as to completely arrest the already sluggish circulation. If such a 
copious and rapidly-forming inflammatory exudate give rise to complete 
stasis over a considerable area, the extent of the resulting necrosis will 
correspond to the district deprived of the requisite blood-supply. The 
same bacteria which produce inflammation frequently, if present in 
sufficient quantities, also cause cell necrosis. Ogston maintains that the 
staphylococci invade the tissues in the form of dense, round masses, 
which advance like clouds of a dense vapor, and, coming in contact 
with the tissues, induce necrosis, the cells, nuclei, and intercellular sub- 
stance being changed into a homogeneous, wax-like substance before 
purulent liquefaction occurs. On the other hand, the streptococci of 
suppuration invade the intercellular spaces, the nuclei of the cells re- 
maining visible. Bonome found the staphylococcus pyogenes aureus in 
such metastatic and broncho-pneumonic foci which presented a gangre- 
nous character. He maintains that the staphylococcus at first produces 
in the lungs a necrosis by its multiplication, and that suppurative in- 
flammation follows later around the necrotic tissue. Putrefaction of the 
dead tissue develops in consequence of the entrance of saprophytic 
bacilli through the bronchial tubes. He verified these assertions by 
experiments. He obtained pure cultures of the yellow coccus from such 
pulmonary foci made by parenchymatous pulmonary injections, and 
succeeded in producing artificially identical lesions in the lungs of 
animals. The same result was obtained by the intra-venous introduction 
of small particles of elder-pith impregnated with pure cultures of the 
3^ellow staphylococcus. The gangrenous foci produced by emboli con- 
taminated with the yellow coccus presented a characteristic appearance. 
The centre of such foci, at an early stage, is composed of necrotic tissue 
and remnants of dead leucocytes. The dead tissue is surrounded by a 



ETIOLOGY. 173 

granular zone, which is again inclosed by a hemorrhagic zone, and 
beyond this an area of catarrhal pneumonia. The staphylococci occupy 
the central portion and from here invade the granular zone, where putre- 
factive bacteria are also found. The pus-microbes do not reach the 
hemorrhagic zone, or the tissues the seat of catarrhal pneumonia. As 
Bonome was unable to produce gangrene of the lung, either by parenchy- 
matous injections of other bacteria, as the pneumococcus or mikrosporon 
septicum, or by aseptic emboli of elder-pith, he naturally came to the 
conclusion that the gangrene resulted from the specific effect of the 
yellow coccus. He compares gangrene of the lung with furuncle of the 
skin from an etiological stand-point. There can be no doubt that the 
primary effect of pus-microbes, when brought in contact with living 
tissue, under certain circumstances, is to produce necrosis before sufficient 
time has elapsed for parenchymatous inflammation to become established. 
This occurs in gangrene of the lung, furuncles, carbuncles, and endo- 
carditis bacteritica staphylococcica. In the ordinary connective-tissue 
abscess, however, the connective-tissue cell undergoes the ordinary in- 
flammatory changes before the} 7 are converted into pus-corpuscles, and 
if gangrene occur it is owing as much to mechanical obstruction to the 
circulation caused by a copious exudate as to the local toxic effects of 
the pus-microbes and their ptomaines. This difference in the action of 
pus-microbes on the tissues depends largely upon the rapidity with which 
they multiply at the point of primary localization. If the microbes are 
rapidly reproduced the chemical substances which they produce in the 
tissues are present in such large quantities that they destroy the cell 
protoplasm, and cell necrosis takes place as the result of their primary 
action ; if the microbes multiply with less rapidity their effect on the 
tissues is less severe, and parenchymatous inflammation is produced 
instead of necrosis. Bonome used large quantities of pus-microbes in 
his injections, and the infected emboli caused circulatory disturbances, 
which only could favor rapid reproduction at the point of primary 
localization. Passet and Liibbert repeated his experiments, but used 
more diluted cultures, and probably on this account they were never 
successful in producing gangrene of the lung, while they frequently 
observed the development of a pulmonary abscess. The centre of a 
furuncle, as well as a carbuncle, is occupied by a mass of dead connective 
tissue, which later becomes detached by suppurative inflammation. The 
connective tissue in these cases is killed by the bacterial cause of the 
suppurative inflammation, which, toward the periphery, appears to 
become mitigated so that, behind the suppurating zone, a wall of granu- 
lation tissue is established which limits further extension of the 
disease. 



174 PRINCIPLES OF SURGERY. 

Specific Bacteria. — All bacteria which can produce an inflammation 
sufficiently severe to completely arrest circulation can become an 
indirect cause of necrosis. Among these can be included the pus- 
microbes and the bacillus of anthrax. The necrosis which occurs regu- 
larly almost in every case of anthrax is probably due to the intensity of 
the inflammation resulting from the presence of the anthrax bacillus, to 
secondary infection with pus-microbes, or to the combined effect of both 
microbes. The absence of necrosis in artificially-produced anthrax, 
when pus-microbes are excluded by the strictest antiseptic precautions, 
does not prove that the anthrax bacilli possess no necrotic effect on the 
tissues, as in such instances death follows so soon that not sufficient 
time intervenes between the inoculation and the death of the animal for 
the local inflammation to terminate in necrosis. Necrosis is, however, 
much more likely to occur if the anthracic infection is complicated by 
the presence of pus-microbes. It is well known that certain chemical 
substances have the power to produce cell necrosis independently of 
their action to excite inflammation. Digitoxin, a poisonous principle 
of digitalis, is one of these. The primary effect of this substance on the 
tissues is to produce cell necrosis. We should expect that some of the 
ptomaines possess similar properties. Orthmann made some very inter- 
esting experiments in this direction with pus-microbes. He inoculated 
both corneae in rabbits by making a puncture with a needle infected with 
a pure culture of the streptococcus pyogenes. One of the eyes was irri- 
gated for ten minutes with a warm physiological solution of salt, 
by using an apparatus constructed for this special purpose. In the eye 
not thus treated a suppurative keratitis was initiated by the leucocytes 
from the conjunctival sac reaching the infected field, while in the cornea 
treated by irrigation the streptococci invaded the vascular spaces, and, 
multiplying with great rapidity, produced by their accumulation dilata- 
tion of the spaces and necrosis of the fixed tissue-cells. 

In most of these cases the central necrosis led to perforation of the 
cornea and complete destruction of the eye. As the corneal corpuscles 
in the necrotic area had lost their nuclei and the parenchyma cells 
showed no signs of inflammation, we cannot escape the conclusion that 
cell necrosis was induced by the direct action of the ptomaines, elabo- 
rated by the masses of streptococci in the vascular spaces. The most 
conclusive proof of the destructive effect of ptomaines on the tissues has 
been furnished by the great master and founder of modern bacteriology, 
Robert Koch. In his experiments on septicaemia in mice he found, 
besides bacilli, a micrococcus in the neighborhood of the place of injec- 
tion. Of the numerous kinds of bacteria contained in the putrid fluid 
used for injection, only the fine bacilli upon which the induction of the 



ETIOLOGY. 



175 



septicaemia depended and the chain cocci found a suitable soil in the 
mouse, while all the rest perished. The chain coccus was never found in 
the blood, but only in the tissues at the seat of infection. He found it 
exceedingly difficult to isolate it from the bacillus. At last he succeeded 
in cultivating it in the field-mouse, which, as experiments proved, is 
immune to the bacillus of septicaemia. The chain coccus injected into 
the subcutaneous tissue of the ear of the field-mouse invaded the tissues 
slowly, causing paleness and death of the cells without extravasation. 
The microbe entered and plugged the capillary vessels, but never found 






'TV v 3 *- i&tv M 



\ 



B 



FlG. 76.— EXPERIMENTALLY-PRODUCED GROWTH OF STREPTOCOCCI IN CENTRE 

of Cornea of Rabbit. Horizontal Section, X 40. {Baumgarten.) 
A, normal cornea; B, central necrotic portion, corresponding in outline to the star-shaped streptococci culture. 

its way into the general circulation. Examination of the specimens 
showed that progressive gangrene occurred in advance of the microbes, 
hence could have occurred only by the action of ptomaines diffused 
through the tissues ahead of the microbic invasion. Inflammation of 
the fixed tissue-cells occurred around the zone of gangrene, and all 
leucocytes which reached the infected field perished. If the same animal 
was inoculated at the root of the tail, gangrene occurred and spread in a 
central direction, and resulted in death on the third day. The microbe 
did not change in its morphology or pathogenic properties after passing 
through a series of inoculations. Both Ogston and Rosenbach are of 



176 PRINCIPLES OF SURGERY. 

the opinion that the chain micrococcus with which Koch produced 
progressive gangrene in the field-mouse is identical with the strepto- 
coccus pyogenes. This question will have to be decided by future re- 
search, which must have for its object the isolation and cultivation of the 
chain coccus from the necrosed tissues of the field-mouse. Baumgarten 
is of the opinion that microbes can produce necrosis not onty by the 
production of a tissue poison, but also lty causing decomposition and by 
the assimilation of material necessary for cell nutrition. The explanation 
advanced by Koch fifteen 3^ears ago, however, appears more rational : 
" Introduced by inoculation (chain cocci) into living animal tissues, they 
multiply, and as a part of their vegetative process they excrete soluble 
substances which get into the surrounding tissues by diffusion, and 
when greatly concentrated, as in the neighborhood of the micrococci, 
this product of the organisms has such a deleterious action on the cells 
that these perish and finally disappear completely. At a greater distance 
from the micrococci the poison becomes more diluted and acts less 
intensely, only producing inflammation and accumulation of lymph- 
corpuscles. Thus it happens that the micrococci are always found in 
the gangrenous tissue, and that in extending they are preceded by a wall 
of nuclei which constantly melts down on the side directed toward 
them, while on the opposite side it is as constantly renewed by lymph 
deposited afresh." 

An almost identical form of gangrene, as experimentally produced 
in the field-mouse by Koch, is occasionally met with in man. It is 
known as progressive gangrene, and is so called from its most conspicu- 
ous clinical feature — rapid extension. Before antiseptic surgery was 
known it frequently developed in cases of compound fracture and com- 
pound dislocation of large joints, and often proved the direct cause of 
loss of limb or life, or both. Two cases came under my own observation 
where it occurred after extirpation of carcinoma of the breast, in one 
without, and in the other with, removal of the axillary glands. In both 
cases the first symptoms appeared on the third day. The general 
symptoms were those of intense sepsis, while the local conditions 
resembled first what used to be called phlegmonous erysipelas. An 
erysipelatous blush appeared at the margins of the wound and extended 
rapidly in all directions, accompanied by infiltration of the deep tissues. 
The gangrene attacked the tissues first involved and followed the course 
of the phlegmonous inflammation. In spite of the most energetic local 
and general treatment, both patients died at the end of the first week. 
Rosenbach describes two cases that came under his care. In one the 
disease started from a small wound of a finger, the process finally 
extending to the lower extremities, with death on the sixth day. In 






ETIOLOGY. 177 

the second case, the local lesion appeared first as a red induration, 
around which oedema developed rapidly, the skin covering the part 
presenting a reddish-blue discoloration before gangrene set in. This 
patient had an eruption of the skin over the whole surface of the body 
which resembled the rash of scarlatina. From the lesions of both of 
these cases Rosenbach cultivated upon peptone-meat gelatin the strepto- 
coccus pyogenes. Ogston calls this affection erysipelatoid-wound gan- 
grene, and always found in the gangrenous tissue the streptococcus. 
Gangrene produced by staphylococcus, the same author calls sloughing 
inflammation or inflammatory mortification. The streptococcus of 
erysipelas never produces gangrene, and when this complication occurs 
in this disease it is always a positive indication that secondary infection 
with pus-microbes has taken place. 

Putrefactive Bacteria. — Necrosis occurring from the action of any 
other microbes than those of putrefaction is not attended by any disa- 
greeable odor or other evidences of putrefaction, and, if limited in extent 
and protected against the invasion of saprophytes, the dead tissue, if 
limited in quantit} 7 , may be completely removed by absorption. Putre- 
factive bacteria feed on dead tissue, and in the absence of such they are 
comparatively harmless. Putrefaction only takes place in moist gangrene, 
and is always caused by the invasion of dead tissue with one or more 
species of saprophytes. Progressive gangrene, complicated by secondary 
infection with saprophytes, is characterized by the formation of gases 
which give rise to emphysema. Progressive gangrene with emphysema is 
one of the most fatal of all wound complications, as the ptomaines elabo- 
rated b} 7 the saprophytic bacilli greatly increase the danger from sepsis. 
Sulphuretted hydrogen is one of the gases formed during putrefaction of 
necrosed tissue. Rosenbach cultivated from the infected tissues, in two 
cases of progressive gangrene with emphysema, a saprophytic bacillus 
with spores. Hauser cultivated from putrefying organic substances one 
or more kinds of the proteus, the proteus mirabilis (Zenkeri) and vulgaris. 

Trauma. — The vitality of a part is completely destroyed if a trauma 

is sufficient in intensity to arrest the circulation completely, and of such 

a character and extent as to render a return of it impossible. Such 

injuries, for instance, are caused by the passage of a car-wheel over a 

limb, where the skin often remains intact, while all of the deeper tissues 

are completely crushed. A blow against a part of the bod} 7 where only 

a thin layer of tissue is interposed between the skin and an underlying 

bone may crush the subcutaneous tissue to such an extent as to preclude 

the possibility of a return of an adequate circulation, and necrosis follows 

as an inevitable result. Deep-seated contusions from the application of 

external violence are often attended by circulator} 7 disturbances, which 

12 



178 PRINCIPLES OF SURGERY. 

necessarily result in necrosis. Necrosis of ganglion-cells following con- 
tusion of the brain affords a good illustration of the occurrence of 
traumatic necrosis at a distance from where the force was applied. In 
such cases the cells are separated from all their anatomical connections 
by the trauma, and either undergo calcification or are removed by ab- 
sorption. If such a contused area become the seat of a subsequent 
infection, suppuration or putrefaction can occur, according to the location 
of the part injured, infection taking place with pyogenic microbes or 
saprophytes. In the so-called railway-spine the cell necrosis following a 
contusion of the spinal cord leads to remote, central, and peripheral 
disturbances. A trauma may be of such a nature as to inflict an injury 
not incompatible with the integrity of a limb, but may create conditions 
which subsequently result in complete obliteration of a main artery. If 
an artery is subjected to serious pressure or traction, the intima gives 
way and the lumen of the vessel is subsequently obliterated by the forma- 
tion of a thrombus at the seat of injury. In such a case the artery is at 
first permeable, and the distal pulsations are unaffected until the lumen 
of the vessel is narrowed and finalty completely obliterated by the forma- 
tion of a thrombus. The late Professor von Wahl has called attention 
to an early and important symptom in these cases, the detection of which 
enables the surgeon to recognize the vessel injury before the appearance 
of the positive peripheral symptoms, viz., a bruit, which can be heard by 
placing the stethoscope over the seat of injury. The vessel injury in 
such cases is of serious import, as the contusion of the soft tissues 
which is usually also present retards or prevents the formation of an 
adequate collateral circulation, and gangrene occurs in consequence of 
complete interruption of the arterial circulation. A vein may be injured 
in a similar manner, and the venous stasis following obliteration by a 
thrombus may become a determining cause of gangrene of a limb, the 
vitalit}^ of which has been otherwise impaired by the injury. 

Decubitus. — Prolonged uninterrupted pressure causes necrosis by 
interrupting the circulation. Tight bandaging and pressure of splints 
have often been productive of gangrene. Bed-sores are liable to form in 
patients suffering from acute infectious diseases, and in persons suffering 
from fracture of the spine, or disease of the spinal cord ; also, in aged obese 
persons treated in the recumbent dorsal position for fracture of the neck of 
the femur. Decubitus is most prone to appear in consequence of pressure 
over bony prominences, and on this account we look for it in persons 
who are going through a long-enforced confinement in bed, first over the 
sacrum, the trochanteric regions, the spinous processes of the vertebrae, 
and the heels, parts most affected b} r the dorsal decubitus. The deleteri- 
ous effect of pressure is greatly aggravated by filthy surroundings, as 



ETIOLOGY. 179 

under these circumstances the necrosed tissue becomes the seat of infec- 
tion with pus-microbes and sapropl^tic bacteria, which inaugurate a 
progressive gangrene and sepsis, often constituting the direct cause of 
death. It is not unusual, in cases of septic decubitus, to find the whole 
sacrum exposed, and in one instance that came under the author's obser- 
vation the spinal canal was opened and through the opening the cerebro- 
spinal fluid escaped, first clear, later purulent. This patient lived for 
several days after the cerebro-spinal fluid had commenced to escape, and 
before his death he presented symptoms which indicated that the menin- 
gitis had extended to the envelopes of the brain. 

Defective Arterial Blood-Supply. — The aseptic ligature, combined 
with the antiseptic treatment of wounds, has been the means of greatly 
diminishing the frequency of gangrene after ligation of the principal 
arteries of a limb in their continuity. Gangrene usually occurred, not 
so much from the sudden interruption of the arterial blood-supply as 
from the septic inflammation following the operation, which interfered 
with the formation of a satisfactoiy collateral circulation. 

Ligation of Arteries in their Continuity. — Statistics of a number of 
years ago show that gangrene has followed ligation of the subclavian in 
the outer third in 9 per cent, of the cases reported ; external iliac, 15 
per cent. ; common femoral, 11 per cent. The results after ligation of 
these vessels have much improved since the introduction of the aseptic 
ligature. In a healthy person with normal blood-vessels there is but 
little danger of gangrene following the ligation of the principal arteries 
of a limb with an aseptic ligature under antiseptic precautions. Gradual 
obliteration of an artery by a thrombus is not attended by equal danger 
of the occurrence of gangrene as when the same vessel is suddenly and 
completely blocked by impaction from the arrest of an embolus, because 
circulation is on a fair way of becoming established before the lumen of 
the vessel is completely closed, while in the latter case the demand on 
the collateral vessels is more urgent and sudden, and consequentlj- the 
failure on their part to act as substitutes for the obliterated trunk is 
more frequent. Valvular disease of the heart, fatty degeneration of this 
organ, atheroma of the arteries, — in fact, all pathological conditions 
which diminish the vis a tergo are instrumental in the causation of gan- 
grene, when from an}' accidental cause or operative interference the 
blood-supply to a limb has been diminished, or when the tissues are the 
seat of a progressive septic inflammation. Gradual diminution of the 
arterial blood-supply general^ gives rise to dry gangrene, as is the case 
in senile gangrene, while sudden interruption of the circulation through 
a large artery from the application of a ligature or the impaction of an 
embolus is usually followed by moist gangrene. 



180 PRINCIPLES OF SURGERY. 

Obstructed Venous Circulation. — Impeded venous circulation is 
fraught with as much danger, as far as the production of gangrene is 
concerned, as obstruction of the arterial circulation. Langenbeck was 
impressed with this fact so strongly that he recommended, if it became 
necessary to ligate one of the principal veins of an extremity near the 
trunk, to ligate at the same time the accompanying artery in order to 
guard against the evil results following ligation of a large vessel. Anti- 
septic surgery has minimized the danger of ligaturing, for instance, the 
axillary or femoral vein, and no surgeon at the present time would deem 
it necessary, or even justifiable, to ligate the corresponding arteries 
simply for the purpose of preventing excessive venous engorgement and 
of favoring the formation of an adequate venous collateral circulation. 
The same advantages which have resulted from antiseptic operations for 
the timely formation of an arterial collateral circulation after ligature of 
an artery are secured for the maintenance of an inadequate venous cir- 
culation after the ligation of a vein. Venous obstruction from patho- 
logical causes often proves more disastrous, as the causes which have 
brought about the formation of a thrombus frequently do not remain 
local, and the thrombus increases in length in both directions, thus 
rendering the formation of a collateral circulation a difficult, if not an 
impossible, occurrence. As venous obstruction gives rise to oedema 
gangrene, if it occur under these conditions, always represents the moist 
variety, and is usually accompanied by putrefaction. 

Heat. — Heat produces pathological conditions according to the de- 
gree of the temperature and the length of time a part is exposed to its 
action. A momentary exposure even to a high temperature produces 
only a burn of the first degree ; that is, simply an active Irypersemia and 
redness of the surface. If the part is exposed for a somewhat longer time 
the hyperemia is followed by a superficial inflammation and blisters 
form, — a condition which is described as a burn of the second degree. In 
such cases the necrosis is limited to the epidermis, which is detached from 
the papillary layer by the serous transudation. In burns of the third 
degree the deeper tissues are destroyed by the heat, and extensive necrosis 
is the result. Cohnheim determined that a temperature from 54° to 58° C. 
was sufficient to produce gangrene in the rabbit's ear. If he immersed the 
ear for a short time in water heated to this temperature, necrosis always 
followed. A somewhat lower temperature continued for a longer time pro- 
duced the same effect. Heat produces necrosis by coagulating the cell-pro- 
toplasm, if its action is superficial; if it penetrate more deeply, the blood 
in the blood-vessels is coagulated, and necrosis of the tissues deprived 
of circulation in this manner follows as an inevitable result. Intestinal 
ulceration, in case of extensive burns, is also a necrotic process, caused 



ETIOLOGY. 181 

by capillary obstruction with dead or dying blood-corpuscles derived 
from the burned district. It has been found experimentally that a 
temperature over 45° C. has a destructive effect on the blood-corpuscles. 
Welti ascertained that if the ear of a rabbit is kept immersed in 
water, gradually heated to 70° C, bleeding from the nose and hemo- 
globinuria followed, — symptoms which he attributed to partial or 
complete obstruction of capillary vessels with the third corpuscle of the 
blood. 

Cold. — The action of cold in producing necrosis is closely allied to 
that of heat. Frost-bites are classified the same as burns. Cold, like 
heat, causes gangrene by producing by its action cell necrosis and vas- 
cular obstruction. 

Cohnheim produced gangrene of the rabbit's ear by exposing it 
for a short time to a temperature of 16° C. The length of time a 
part is exposed, either to heat or cold, exerts an important influence 
in determining the extent and depth of the subsequent gangrene. 
Gangrene resulting from a burn or exposure to cold remains dry and 
aseptic as long as the entrance from without of pus-microbes and sapro- 
phytes is prevented, but with microbic invasion suppuration and putre- 
faction are established. 

Caustics. — Chemical substances which by their local action on the 
tissues produce extensive cell necrosis are called caustics. Of these the 
strong acids and mineral salts destroy cells by causing coagulation. 
The necrosed tissue, or eschar, resulting from their action is firm, and 
the contour of the cells is well preserved. The alkaline caustics, on the 
other hand, dissolve the tissue elements, and the slough resulting from 
their application is soft. A peculiar form of necrosis of the maxillary 
bones occurs in persons exposed to the fumes of phosphorus. The most 
recent explanation of the occurrence of necrosis of the jaws in persons 
employed in match-factories is to the effect that the phosphorus fumes 
in the mouth are transformed into phosphoric acid, and that necrosis of 
the bone is produced by the direct action of the acid on the bone and 
myeloid cells, while the periosteum remains intact and produces new 
bone. 

Epgot. — The prolonged administration of ergot in large doses is 
attended by the risk of causing gangrene. The gangrene from ergotism 
is always of the dry variety. It is generally believed that it is caused 
by the drug keeping up an angio-spasm, which shuts off the full blood- 
supply to the peripheral portion of the extremities, — the most frequent 
seat of the gangrene. Zweifel, of Erlangen, believes that the toxic effect 
of ergot results in a vasomotor paresis, and that the gangrene is due to 
defective innervation. 



182 PRINCIPLES OF SURGERY. 

Raynaud's Disease. — Symmetrical gangrene, or Raynaud's disease, is 
a form of ischsemia due to contraction of the arterioles. The arterial 
spasm may extend to arteries the size of the radial. Raynaud recom- 
mends the use of the constant descending currents to the spine. 

Internal Necrosis. — In simple cell necrosis the tissue elements may 
have undergone no changes in form, but the cell-protoplasm has lost its 
vital properties and function has been completely arrested. Such cells 
present a cloudy appearance, and if the necrosis has resulted from a 
gradual or sudden ischsemia the part affected presents a pale appearance. 
In the periphery of such a necrotic area the vessels become dilated and 
an hyperaemic zone forms, in which the collateral circulation is to be 
established. If an arterjr in any of the internal organs is suddenly 
obliterated by the impaction of an embolus, the tissues supplied by the 
closed vessels are deprived for a time, and perhaps permanently, of their 
blood-supply, and in consequence of this they become pale, while around 
the wedge-shaped, anaemic territory the vessels concerned in the forma- 
tion of collateral circulation are distended to their utmost, and often 
yield to the increased intra-vascular pressure when extravasation of blood 
occurs. If the collateral circulation is not speedily established, necrosis 
of the tissues supplied by the obliterated vessel is the result. In nicotic 
cell necrosis karyolysis — that is, dissolution of the cells — usually occurs. 
If the cell-membrane rupture and the contents of the cell escape, we 
speak of a karyorhexis. Absolute ischsemia of certain parts or cell 
territories continued for only one to two hours is sure to result in 
necrosis. If any portion of the brain, intestines, or kidney is deprived 
of blood-supply for this period of time, nutrition is completely sus- 
pended, and cell necrosis follows as an inevitable consequence. Litten 
ligated the renal artery in animals, and found, at the end of an hour and 
a half to two hours, the renal epithelia in a state of necrosis. Limited 
necrosis of the parenchyma of the brain may give rise to focal symptoms 
hy which the lesion cannot only be recognized, but often accurate^ 
located. Infarcts of the kidney can frequently be diagnosticated by a 
careful chemical and microscopical examination of the urine. A similar 
condition in the lungs gives rise to circumscribed catarrhal pneumonia, 
which can be recognized by a careful physical examination of the chest. 
Ulcer of the stomach, the result of a circumscribed necrosis, is attended 
by a coinplexus of sjanptoms pointing directly to the seat and nature of 
the lesion. Necrosis in internal organs is seldom followed by putrefac- 
tion, as saprophytes seldom reach the dead tissue. Necrosis of the lungs 
is sometimes followed Ivy gangrene, by the entrance into the necrosed 
tissue of putrefactive bacteria from the respiratoiy passage. 

Gangrene of External Parts. — As it is often impossible to recognize 



SYMPTOMS. 183 

during life a limited cell necrosis in the internal organs by the symptoms 
presented, this subject has been briefly disposed of, but the symptoma- 
tology of external gangrene will receive a more thorough consideration. 
It might appear that the recognition of the existence of gangrene of any 
of the external parts would require no special care or erudition. But this 
is not so. It is true that, when gangrene is fully developed, when all the 
characteristic symptoms are present, a correct diagnosis can be made on 
first sight. But cases occur where it is exceedingly difficult to determine 
whether the part affected is dead or only in a state of inflammation. In 
illustration of this the author will only allude to the difficulties which 
surround the surgeon in many cases of herniotomy, when he has to 
determine whether it is justifiable to return a portion of intestine that 
has been strangulated for some time if he simply rely on the appearance 
of the intestine. The intestine presents a dusky, almost black, appear- 
ance, and the casual observer might come to the conclusion that it is 
gangrenous and treat it as such, when, in fact, a more careful observation 
will soon reveal the fact that the circulation is not completely arrested, 
and that it is safe to return it. 

SYMPTOMS. 

(a) Pain. — Sudden, severe, often excruciating pain in a limb is the 
first indication which announces the occurrence of embolism in one of 
the large arteries. In the lower extremity the embolus is often arrested 
at the bifurcation of the popliteal artery, but the pain extends along the 
whole limb, from the toes to the groin. The sudden anaemia is the cause 
of the pain. In senile gangrene the gradual ischsemia caused by the 
atheromatous degeneration of the arteries gives rise to pain and a sen- 
sation of numbness, which precede the gangrene for weeks or months. 
Acute inflammation resulting in gangrene is attended by intense pain 
from the very beginning ; the pain abates, as a rule, with the occurrence 
of gangrene. Pain may be absent at the seat of necrosis, and referred 
to some other part or locality. In strangulated hernia the patient often 
suffers little or no pain at all in the swelling, but complains of a period- 
ical pain in the region of the umbilicus. The absence of pain and tender- 
ness over the region of a hernia speaks rather for than against the presence 
of gangrene. Osteomyelitis is attended b} r severe pain, which is dimin- 
ished or subsides with the escape of the products of inflammation from 
the bone into the surrounding tissues. In cases of intestinal obstruction 
the cessation of pain, with continuance of the symptoms of obstruction, 
is an indication that gangrene has occurred. 

(b) Tenderness. — The pain elicited by pressure is a more important 
symptom in the diagnosis of necrosis than spontaneous pain. As long 



184 PRINCIPLES OF SURGERY. 

as the part suspected to be necrotic is sensitive to the touch it is a sign 
that necrosis has not taken place. To test the sensation of a part it is 
advisable to resort to puncture with an aseptic needle. Absence of pain 
and all sensation on puncturing the tissues with a needle is often the best 
argument to convince the patient and friends that necrosis has occurred. 

(c) Temperature. — The difference in the temperature of a part threat- 
ened with gangrene has given rise to the expressions hot and cold gan- 
grene. If gangrene follow an acute inflammation the local temperature 
remains high until other evidences of gangrene make their appearance, 
when the complete arrest of circulation and tissue metamorphosis result 
in a sudden fall of the local temperature. In gangrene following atheroma, 
thrombosis, embolism, and ligation of arteries the local temperature is 
reduced before gangrene occurs. 

(d) Pulse. — After ligation of the principal artery of a limb the sur- 
geon examines anxiously, from day to day, for the appearance of pulsa- 
tion in the distal portion of the artery, — an occurrence upon which 
depends the fate of the limb. The re-appearance of the pulsation in the 
distal part of the artery is a certain indication that collateral circulation 
has become established, and that gangrene will not occur. With the 
appearance of distal pulsations the local temperature increases, and the 
diminished tissue metamorphosis is restored to its normal state. In 
embolism or thrombosis of a large artery the same disturbances in the 
peripheral circulation of the limb are observed as after ligation. By 
searching for pulsation in different parts of the limb the surgeon can 
often locate the thrombus or embolus. If, for instance, the embolus or 
thrombus is located in the terminal portion of the popliteal artery, pulsa- 
tions of the femoral artery can be felt from Poupart's ligament down to 
the seat of obstruction, while no pulsations below this point can be felt 
until collateral circulation is established. Obliteration of an artery from 
pathological causes is prone to prevent the formation of an adequate 
collateral circulation by the growth, in both directions, of the thrombus 
or embolus. The pulse furnishes the most important means to follow 
from day to day the growth of the intra-vascular blood-clot. In senile 
gangrene a thrombus frequently forms in one of the smallest arteries 
and grows in a proximal direction, extending from the digital branches 
to the dorsalis pedis, to the anterior tibial, or from the plantar arteries to 
the posterior tibial, the popliteal, and finally the femoral. In such cases 
the arteries can be felt as firm cords, but pulsations are limited to the 
pervious portion of the vessels. An embolus often becomes the centre 
of an enormous thrombus, which seriously impairs the chances of pres- 
ervation of the limb by the establishment of an early and adequate 
collateral circulation. When an embolus obstructs the popliteal artery, 



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SYMPTOMS. 185 

pulsations can be felt above this point, but they disappear with the 
extension of the secondary thrombus in a proximal direction. 

(e) Swelling. — In moist gangrene the necrosed tissue imbibes moist- 
ure to a considerable extent, and the slough is larger than the tissue it 
represents. The swelling is increased twice as much when gas forms in 
the tissues. In dry gangrene the parts shrink, become firmer, and 
instead of swelling there is diminution in their size as compared with 
their volume in a normal state, — a condition called mummification. 

(f) Emphysema. — The presence of empli3 r sema in gangrenous tissue 
is a certain indication of the presence of gasogenic bacteria. The char- 
acter of putrefaction depends on the kind of saprophytes which are 
present in the dead tissues. The different kinds of proteus possess gas- 
producing properties. The proteus, according to Hauser, appears in dif- 
ferent forms, according to the chemical reaction of the soil upon which it 
grows. On acid gelatin the culture consists of cocci and short bacilli ; 
on alkaline gelatin it grows in the form of threads, vibrios, spirilli, etc. 
All these different forms of proteus growing in dead tissue exposed to 
the atmospheric air produce sulphuretted hj'drogen. Hauser cultivated 
the proteus from ulcerating carcinomas and bed-sores. Chiari reports 
an interesting observation concerning the production of a septic emphy- 
sema and gangrene caused by the bacillus coli communis. The patient 
was suffering from diabetes and atheroma. The great toe was amputated 
for gangrene. Gangrene of the foot followed, which extended above the 
ankle. Gussenbauer amputated above the knee-joint. Gangrene of the 
stump, with extensive empl^sema, supervened and the patient died a few 
daj'S after the operation. The bacillus coli communis was found in the 
affected tissues and the blood, and was cultivated in ao-ar-gelatin and 
grape-sugar. The gasogenic properties of this microbe were well shown 
in the cultures. All attempts to produce septic emphysema in animals 
with pure cultures failed, as the animals died of acute sepsis. In the 
cases of progressive gangrene with emphysema examined bacteriolog- 
ically by Rosenbach, he found the bacillus saprogenes foetidus. Emph} 7 - 
sema is sometimes so marked that on percussion a tympanitic resonance 
is elicited. When less in degree its presence can be readilj' recognized 
by pressure, which causes a crackling, crepitating sound. 

(g) Color. — If gangrene take place in consequence of interrupted 
arterial circulation, the part at first presents a preternaturally pale ap- 
pearance until the first visible evidences of the actual occurrence of 
gangrene are announced by a livid or lead color, at a point where the 
circulation has first been completely arrested. The lividity, when it is 
due to complete, irreparable capillary stasis, is not affected by pressure. 
Blisters containing a sanious fluid form at points where the deeper tissues 



■. 



186 PRINCIPLES OF SURGERY. 

have already undergone necrosis. As soon as the circulation has been 
completely arrested, tissue metamorphosis is at once suspended, and the 
further changes are entirely of a chemical nature. The colored corpus- 
cles of the blood undergo rapid disintegration ; the coloring material is 
diffused through the dead tissue and into the interior of the bullae. The 
black color of gangrenous tissue is produced by sulphuret of iron, — a 
combination of sulphuretted hydrogen and haemoglobin. 

(h) Condition of Tissues. — The condition of the dead tissues will de- 
pend on the cause of the necrosis. In dry gangrene they become firmer 
by evaporation of the fluids. In moist gangrene they imbibe fluids and 
undergo maceration, becoming soft and friable. In moist gangrene a 
fetid, sanious fluid escapes from the dead tissue. Adipose tissue in a 
condition of gangrene undergoes speedy disintegration, and free globules 
of fat are mixed with the sanious discharge. Maceration of tissue is 
considered by Ravoth as the most important condition in determining 
the presence of gangrene in cases of strangulated hernia. He maintains 
that if the tissues of the intestinal wall can be readily separated and 
teased asunder with a dissecting forceps there can be no doubt that 
gangrene has occurred. This maceration, however, takes place only some 
time after the circulation has ceased, and is entire!} 7 absent in necrosis of 
bone, cartilage, and tissues well supplied with elastic elements, as the 
arteries. In determining the presence of gangrene in strangulated hernia, 
where an} 7 doubt as to its presence exists in the mind of the operator, 
it is much better to liberate the strangulated gut, draw it forward and 
irrigate it ever} 7 few minutes with a hot solution of boric acid, which will 
stimulate the sluggish circulation, and will soon furnish reliable proof of 
the actual condition of the vessels and the tissues. . Mechanical stimu- 
lation of the intestinal wall is also a valuable diagnostic measure, as, if 
gangrene has occurred, no amount of irritation will excite peristaltic 
action, while with the restoration of the impeded circulation the mus- 
cular fibres will respond to irritation. 

(i) Odor. — Necrosed tissue does not emit any unpleasant odor 
unless it has become invaded with putrefactive bacteria. The almost 
unbearable stench which attends extensive moist gangrene is always the 
result of putrefactive changes. Dry gangrene is odorless. In acute 
inflammatory affections of the lung, where a communication has been 
established between the inflammatory focus and the bronchial tubes, the 
presence or absence of foetor is of great diagnostic value, as its presence 
speaks in favor of gangrene and its absence indicates an abscess. 

(j) Mummification. — By this term we mean a drying up of a gan- 
grenous soft part from the loss of fluids which it contains by evapora- 
tion. It is a state of preservation of dead tissue while still attached to 






SYxMPTOMS. 187 

the living body. It can only occur if the dead tissue is exposed to the 
atmospheric air, and on this account it is always absent in necrosis of 
internal organs. Mummification can only take place where putrefaction 
is absent, and, therefore, is most frequently met with where gangrene is 
first limited, and increases gradually by an aggregation of the causes 
which produce gradual diminution of the arterial blood-supply, as in 
cases of senile gangrene. 

(k) Line of Demarcation.— The line of demarcation is the line where 
the farther extension of gangrene has been arrested by an adequate col- 
lateral circulation and a wall of living granulations. Back of this line 
of demarcation, on the side of the living tissues, there is to be found an 
hypersemic zone, which precedes and attends the regenerative process, 
and by which the farther extension of the gangrene is prevented. In 
septic gangrene the line of demarcation marks the limits of the area 
of infection, while in aseptic gangrene it indicates the point where the 
vascular conditions answer the physiological requirements of the part. 

(I) Elimination of Gangrenous Part. — Spontaneous elimination of a 
gangrenous part is of frequent occurrence. The necrotic tissue may be 
disposed of in a spontaneous cure in three different ways : 1. Absorption 
of dead tissue. 2. Separation of necrosed part by granulation. 3. 
Separation of the sphacelus or sequestrum b}' suppuration. A limited 
quantity of necrosed aseptic tissue can be completely removed by ab- 
sorption in the same manner as absorbable aseptic substances are 
removed when implanted in the tissues. This is the most desirable 
termination of gangrene, and takes place frequentty in cell necrosis of 
the internal organs. Such a disposal of aseptic necrosed tissue is also 
possible on the surface of the skin when the area does not exceed a 
square inch, and an aseptic condition is secured throughout. The 
capacity of the tissues to remove aseptic necrosed tissue is limited, and 
when the quantity of tissue surpasses this capacity the dead part is con- 
siderably diminished in size, and the balance is detached by the granula- 
tions which form at the line of demarcation, and is finallj 7 eliminated 
spontaneously or by operation. Repair after this manner of elimination 
is rapid and satisfactory. . If infection with pus-microbes has taken 
place in the beginning of the lesion which has caused the necrosis, or, 
later, at the line of demarcation, separation of the slough takes place by 
means of a suppurative inflammation. In such cases the dead part is 
not diminished in size, and the healing, after its elimination, takes place 
more slowly, and the result, as a rule, is less satisfactory. Separation 
takes place very slowly in necrosis of bones, intermuscular connective 
tissue, and tendons, requiring often weeks and months before the dead 
tissue «can be removed. 



188 PRINCIPLES OF SURGERY. 

(m) Liquefaction of Necrosed Tissue. — In internal necrosis where 
no putrefaction or suppuration takes place, and the amount of necrosed 
tissue exceeds the absorptive capacit} r of the surrounding tissues, lique- 
faction takes place, and months and years later the seat of necrosis is 
occupied by what appears, and has often been falsely described, as a 
cyst. This method of disposing of the dead tissue is observed most 
frequently in organs scantily supplied with connective tissue, as the 
brain and spinal cord and in adipose tissue. 

(n) Encapsulation. — A limited area of aseptic necrosed tissue, not 
amenable to absorption, is often rendered harmless by encapsulation. 
The surrounding living tissue throws out a wall of granulation tissue 
which is converted into connective tissue, forming a capsule around the 
dead tissue. This method of disposal of dead tissues frequently occurs 
in the internal organs. A sequestrum occasionally becomes encapsulated 
after the interior of an involucrum has been rendered spontaneously, or 
by treatment, aseptic. 

(o) General Symptoms. — These will have reference to the loss of 
function caused by cell necrosis in internal organs and sepsis in external 
necrosis. Function will be affected according to the location and extent 
of cell necrosis. If cell necrosis is of mycotic origin and general it fre- 
quently becomes a direct cause of death. If it is limited to a single 
organ the symptoms will point to it as the seat of the disease. Limited 
areas of cell necrosis, in most of the organs, may give rise to ill-defined 
or no S} r mptoms whatever, and are then complete!} 7 beyond the grasp of 
a correct diagnosis. The most important general symptoms of gangrene 
arise from the introduction into the general circulation from the gan- 
grenous part of soluble toxic substances. As this subject will be treated 
of more extensive!}' in the chapter on Septicaemia, it will suffice here to 
make the broad but correct statement that septicaemia complicates gan- 
grene only when the dead tissues are infected with pus-microbes or 
putrefactive bacteria. Dry gangrene is, therefore, not attended by an}' 
danger of septic intoxication ; while patients suffering from moist gan- 
grene witli putrefaction die, as a rule, not from the loss of tissue from 
gangrene, but from sepsis incident to the gangrene. Sepsis in gangrene 
is usually of that variety which arises from the introduction into the 
circulation of preformed toxins, the symptoms subsiding with the 
removal of the cause, with the exception of those cases of progressive 
sepsis caused by infection witli pus-microbes. 



CHAPTER VII. 

Necrosis {continued), 

PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 

The pathological and clinical classification of necrosis is based upon 
its causes, location, extent, and the age of the patient. The causes of 
necrosis have already been considered, and it has been shown that it 
results either from arrest of the circulation from purely mechanical 
causes or from the action upon the tissues of toxic, chemical, or thermal 
influences which destroy the protoplasm of the cells directly. The 
location of the necrosis is important to remember, as when it occurs in 
organs inaccessible to saprophytic micro-organisms putrefaction never 
takes place ; on the other hand, necrosis in parts accessible to atmos- 
pheric air is prone to be followed by putrefaction, with all the dangers 
which attach themselves to this condition. The extent of the gangrene 
has an important bearing on the prognosis, as, when the causes are such 
as to determine a circumscribed form of the disease, life is not in clanger, 
while the progressive form, with few exceptions, ends in death, in spite 
even of the most heroic treatment. The age of the patient often deter- 
mines the form of gangrene, as, for instance, senile gangrene is a disease 
of the aged, while noma, almost without exception, attacks onl} r children. 
The simplest and an exceedingly common form of necrosis is what has 
been described by Weigert as 

Coagulation Necrosis. — This is essentially a cell necrosis. It is 
called coagulation necrosis because the tissues present the appearance 
of coagulated albumen, and also on account of the process resembling- 
coagulation of the blood. Coagulation necrosis is probably identical 
with, or, at any rate, nearly allied to, the hyaline degeneration of Reck- 
linghausen and fibrinous degeneration of E. Wagner. 

The chemical process which results in coagulation necrosis is as 
yet imperfectly understood. Weigert, who was the first to describe this 
form of necrosis, maintains that the cell-protoplasm and, perhaps, all 
albumen-containing substances are converted by it into a substance 
resembling fibrin. Macroscopically, tissues which have undergone this 
form of necrosis present a } T ellowish or whitish appearance, and are of 
variable consistence. Lender the microscope the cells either appear un- 
changed in form or their place is occupied by thread-like fragments and 

(189) 



190 PRINCIPLES OF SURGERY. 

granular material. Weigert lays down as the earliest change witnessed 
in a cell undergoing coagulation necrosis disappearance of the nucleus, 
which is the case twelve to twenty-four hours after the process com- 
menced. Fibrin is a product of coagulation necrosis of the blood. 
According to Alexander Schmidt, during the coagulation of blood the 
colorless corpuscles disappear ; the product of their destruction is fibrin 
ferment and fibrino-plastic material, which, with the fibrinogen of the 
plasma, form fibrin. Isolated cells destroyed by coagulation necrosis 
exfoliate, and are transformed into a homogeneous granular substance, 
which, according to circumstances, is removed by absorption, or becomes 
encapsulated. Cell necrosis en masse is often followed by calcification, 
and on surfaces by ulceration. The transformation of a tubercular 
product into a cheesy mass is the result of coagulation necrosis. As 
essential conditions for coagulation necrosis to occur Weigert enumer- 
ates: 1. Death of tissue-cells. 2. Presence of plasma-fluids. 3. Tissues 
must contain coagulable substances. Coagulation necrosis is retarded 
by the ptomaines of pus-microbes, putrefying material, and living epi- 
thelial cells. An entire organ may be destined by coagulation necrosis. 
Pale infarcts after embolism are products of this change. The so-called 
fibrin wedges, which were formerly regarded as decolorized blood-clots, 
consist of such tissues. At first the cells are normal in outline and 
appearance ; later, the nuclei disappear and the cells break up into 
granular masses. In the internal organs coagulation necrosis is most 
frequently met with in the kidneys, spleen, typhoid deposits, tubercular 
lesions, the vicinity of mycotic foci, and in atheroma of the blood- 
vessels. In the parenchyma of organs it attacks the epithelial cells, 
while the connective tissue remains intact. On mucous surfaces it is 
represented by the diphtheritic and croupous exudations. While the 
chemical processes which take place in coagulation necrosis cannot as 
yet be explained satisfactorily , there can be no doubt that this form of 
necrosis is nearly always, if not always, of mycotic origin, and it must be 
regarded practically in the light of a bacterial necrosis. Kiebs describes 
the same condition askaryolysis, Icaryorhexis,&nd vacuolar degeneration. 
He claims that early disappearance of the nucleus is not an essential, but 
an accidental, condition. In a case of pseudo-diphtheria Klebs found the 
bacilli between cells devoid of nuclei, and only in the centre of the 
necrotic patch did he find bacilli within the cells ; from this he concluded 
that karyolysis is due to the action of chemical products of the bacilli. 
In the second group of mycotic necroses the process differs as in tj T phus. 
Here the necrotic centre, which contains no cells, is surrounded by a zone, 
in which both cells and nuclei are also absent, but which contains a large 
number of chromatin bodies, lying free in the tissues. As these bodies 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 191 

are found in a location where the, cells and nuclei have been destroyed, 
it can hardly be doubted that they represent remnants of these structures. 
According to Wolmkom and Graessle, these bodies are liberated by rupt- 
ure of the nuclear envelope. This method of cell destruction is called 
karyorhexis. A third form of cell necrosis is vacuolar degeneration, in 
which the change is initiated in the protoplasm itself. This must not be 
mistaken for cell oedema. In vacuolar degeneration the protoplasm rupt- 
ures, and the nuclei of epithelial cells, which line a hollow viscus, are 
liberated, as Langhans observed in this form of cell necrosis in the kidne3 T . 
The cell ruptures on account of increased intra-cellular pressure, and 
the process well deserves the name plasma rhexis. This form of cell 
destruction was former^ considered a post-mortem change. For the 
sake of simplicit} 7 it is advisable to substitute for the different forms of 
cell necrosis described by Klebs the general term, coagulation necrosis, 
devised by Weigert. 

Necrobiosis. — This is a term applied by Virchow to the spontaneous 
wearing out of living parts. Death of isolated cells is a physiological 
process as long as they are replaced by new cells of the same tissue type. 
Necrobiosis occurring on a more extensive scale is a pathological con- 
dition, and is etiologically identical with coagulation necrosis. The term 
can be used to signify circumscribed cell necrosis without reference to 
its etiology or minute morbid anatomy. 

Progressive Gangrene. — This form of gangrene is alwa} T s of bacterial 
origin. The microbe most frequently found in the tissues is the strep- 
tococcus p3'0genes. It occurs most frequentl}' after wounds which open 
up a large surface of loose connective tissue, as in compound fractures, 
compound dislocations, excision of the breast, with removal of axillaiy 
glands and extirpation of large, fatty tumors. The streptococcus pyo- 
genes invades the connective-tissue spaces rapidly, somewhat after the 
manner of diffusion of the streptococcus through the lymphatic vessels. 
Much of the connective-tissue necrosis results from the direct action of 
the pus-microbes and its ptomaines on the cells. The necrosis of the skin 
is no indication of the extent of the disease in the deeper tissues. The 
infection is initiated by a chill, and the fever which follows resembles 
severe sepsis from other causes. If infection occur during the operation, 
or at the time of accident, the first symptoms ma} 7 be looked for within 
forty-eight to seventy-two hours. If suppuration has occurred it is 
diminished with the appearance of septic infection, and the discharge 
becomes thinner and sanious. Lymphangitis frequently accompanies 
the deep-seated phlegmonous inflammation. Gangrene appears in the 
tissues first affected, and spreads rapidly along the connective tissue. 
Not only the gangrene is progressive, but also the attending septicaemia. 



192 PRINCIPLES OF SURGERY. 

The larger the area of necrosis, the more extensive the field for the growth 
of pus-microbes and putrefactive bacteria. Progressive gangrene is an 
exceedingly dangerous form of infection, and unless treated by heroic 
measures at an early stage is sure to lead to a speedy fatal termination. 

Progressive Gangrene, with Emphysema. — Etiologically this form of 
gangrene is identical with the preceding plus secondary infection with 
gasogenic bacteria. The necrosed tissue answers the purpose of a 
nutrient medium for saprophytic microorganisms, which not only 
generate gas which is diffused through the dead tissues, but the soluble 
toxic substances which they elaborate in the necrotic area are absorbed 
into the circulation, — an occurrence which gives rise to toxaemia. Em- 
physema almost always extends far bej'ond the limits of the visible 
gangrene, but its presence is a sure indication of the extent of the in- 
fection in the deep-seated tissues. Progressive gangrene, with emphy- 
sema, is the most fatal form of gangrene, and only in exceptional cases 
will the surgeon succeed in warding off a certain fatal termination by 
early operative interference. In both kinds of progressive gangrene the 
part is swollen, oedematous, the skin presenting first a livid, bluish color, 
which afterward shades into a greenish or reddish-black hue. Bullae, 
containing a reddish serum, form at points where the gangrene is spread- 
ing. Besides sulphuretted hydrogen, butjnic and valerianic acids, am- 
monia, sulphur, etc., are some of the many chemical products of putre- 
faction. The rapidity with which progressive gangrene, with and without 
emphysema, spreads has led the French authors to apply to it the term 
gangrene foudroyante. 

Moist Gangrene. — Progressive gangrene is necessarily a moist gan- 
grene, as bacteria cannot germinate without moisture. All forms of 
mycotic gangrene are forms of moist gangrene. All necroses in the 
interior of the body belong to this variety. The moisture of the dead 
tissue is due to imbibition of the oedema-fluid, and consequently moist 
gangrene is apt to follow vascular conditions in which there is some im- 
pediment to the return of venous blood, as in cases of obstruction in a 
large artery, and more especially when a large vein has become obliterated 
by a thrombus. Moist gangrene is attended by all the dangers incident 
to putrefaction. In this form of gangrene the line of demarcation is the 
seat of suppurative inflammation. 

Dry Gangrene. — In dry gangrene the dead tissue undergoes mummifi- 
cation, and on this account the soil is unfitted for the germination of putre- 
factive bacteria. Dry gangrene is usually the result of a trauma, the action 
of a chemical substance, or it follows a gradually increasing diminished 
blood-supply. In senile gangrene it follows in consequence of a gradual 
diminution of blood-supply, owing to atheromatous degeneration of the 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 193 

arteries, while the return of venous blood remains unimpaired. Dry 
gangrene is often an aseptic gangrene. If no infection take place with 
pus-microbes the line of demarcation is formed by granulation tissue, 
and the gangrenous part, if small, is absorbed, or if this is impossible on 
account of its size it is separated by the granulations. If suppuration 
take place this occurs at the junction of the dead with the living tissues. 
Dry gangrene is usually not attended by any general symptoms, and all 
attempts to remove the dead tissue should be postponed until the line 
of demarcation has formed. 

Senile Gangrene. — This is the gangrene of the aged, or, rather, it is 
the gangrene which is caused by atheromatous degeneration of the 
arteries. Senile marasmus, in the form of atheromatous degeneration 
of the arteries, may occur in persons less than 40 }^ears of age, and is 
often absent in octogenarians. Senile gangrene always occurs in parts 
where the circulation is feeblest ; consequently it usually commences in 
one of the toes. If the necrosed tissue remain aseptic the rapidit}' of 
the extension of the gangrene depends on the condition of the blood- 
vessels. It may remain limited to one toe, or it may extend from toe to 
toe, and then creep along the dorsum or plantar surface of the foot, or 
on both sides simultaneously, and extend quite rapidly to the leg as far 
as the knee. Usually the disease extends along the course of one of the 
principal arteries, and extends later to other parts of the foot in con- 
sequence of greater embarrassment of the arterial and venous circula- 
tion. If infection in the vicinity of the necrosed tissue with pus- 
microbes take place, a suppurative inflammation may follow senile gan- 
grene, which will give rise to a progressive and rapidly-fatal form of the 
disease. In the dry form of senile gangrene the tissues mummify, are 
firm, and perfectly black in color. In the moist variety the parts present 
the same appearances as in progressive gangrene. If a line of demarca- 
tion form, the separation of the dead from the living tissues requires 
an unusually long time, as the circulation is enfeebled to such an extent 
that tissue proliferation takes place very slowly. 

Diabetic Gangrene. — It is a well-known clinical fact that persons 
suffering from diabetes are very prone to be attacked by gangrene. The 
reasons for this are as yet unknown. Gangrene occurring from trivial 
causes in persons presenting the appearances of usual health, and in 
whom no evidences of atheromatous degeneration of the arteries can be 
detected, should awaken the suspicion of the existence of diabetes, and 
no time should be lost in making a careful examination of the urine. A 
strictly antidiabetic diet has often resulted in arresting further extension 
of the gangrene. Konig has found that after amputation for gangrene in 
diabetics the quantity of sugar in the urine is diminished. 

13 



194 PRINCIPLES OF SURGERY. 

Decubitus. — Gangrsena per decubitum literally means gangrene from 
pressure. It occurs in consequence of pressure from splints, bandages, 
and the prolonged recumbent position in bed, especially in persons 
suffering from fracture of the spine, or acute infectious diseases attended 
by great impairment of the circulation. Pressure without infection is 
productive of dry aseptic gangrene, but usually gangrene from this 
source is complicated by infection with pyogenic or putrefactive bacteria, 
or both. If gangrene from pressure is inevitable, it is apparent that its 
occurrence should be met by timely precautions for the purpose of pre- 
venting accidental infection. Gangrene from splint pressure can be 
prevented by interposing between the splint and bony prominences a 
thick cushion of salicylated cotton. Bed-sores should be prevented by 
changing the position of patient frequently and protecting the parts 
most exposed to the ill effects of pressure with fenestrated rubber 
cushions, bj T enforcing absolute cleanliness, and by keeping the skin 
in a healthy condition by applications of spirituous lotions. Both in 
gangrsena per decubitum and senile gangrene the necrosis is caused by 
impairment or complete suspension of the capillary circulation. 

Noma. — Noma, cancer aquaticus, is characterized by rapid, gan- 
grenous destruction of the cheek, which usually commences some distance 
from the lips. This disease is exceedingly rare in this country, but quite 
prevalent in the large cities of Europe. It attacks exclusively children, 
occurring most frequently between the ages of 3 and 8 years. Healthy 
children seldom suffer from this disease ; it either appears in badly- 
nourished, cachectic subjects, or it occurs as a complication of some of 
the eruptive fevers or typhus. In reference to the etiology of noma, 
little is known. The almost constant occurrence of the disease in a dis- 
tinct part of the cheek and its limitation to one side of the face would 
indicate that it might be the result of some nervous disturbance. It is, 
however, more probable that it is a form of nicotic necrosis. A few 
observations on the bacterial origin of noma have been made. Lingard 
found in the tissues a long bacillus, which he believed was the cause of 
the disease. In gangrenous stomatitis in the calf, which affects this 
animal at particular seasons of the year, he found bacilli which are very 
similar in appearance to those present in noma in man. On cultivation 
they present characters which render them easily distinguishable from 
other bacteria, and on inoculation of these microorganisms into the calf 
a gangrenous stomatitis is again produced. 

Ranke's investigations on noma led to the following conclusions: 
Different forms of gangrene resulting from noma can unquestionably 
occur spontaneous^ in children who have a tendency to disease of this 
character; that is, without infection from contact. The frequent occur- 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 195 

rence of noma in public institutions, and the apparent preference of the 
disease for localization upon the mucous membrane of the different open- 
ings of the body, suggest that the origin of it may be referred to the in- 
vasion from without of microorganisms. In the zone of tissue contiguous 
to that which has undergone necrosis may be found cocci which in num- 
ber appear like a pure culture. At the periphery of the necrotic zone 
which has been invaded by cocci the connective tissue is found in a state 
of active proliferation. The entire condition is suggestive of the tissue 
necrosis in field-mice, which is caused by a chain coccus, described by 
Koch. Up to the present time the specific nature of the cocci which 
Ranke found in noma tissues has not been shown. Schimmelbusch has 
examined one case for bacteria, and found bacilli, often in pairs and some- 
times in long filaments, growing along the boundary-line of the living 
tissues. The bacillus grew upon gelatin without liquefying it, and pure 
cultures injected into rabbits caused abscesses. Undoubtedly, further 
bacteriological research will prove that noma is a mycotic necrosis, and 
that the dead tissue, like in other forms of necrosis, is subsequently in- 
vaded with putrefactive bacilli. The disease commences as a circum- 
scribed livid spot upon the surface of the mucous membrane of the 
mouth, and a corresponding portion of the cheek in its entirety is indu- 
rated. Soon the color of the affected mucous membrane becomes darker, 
and the skin, which at first presented a dusky appearance, is turned 
nearly black, and the epidermis is elevated in a blister, which afterward 
is turned into a black eschar. With the separation of the gangrenous 
part an opening in the cheek is left without any sign of a line of de- 
marcation. The gangrene spreads in all directions, and, if not arrested 
spontaneously or by the use of energetic measures, often destroys the 
entire cheek. The disease is not limited to the soft tissues, but attacks 
the maxillary bones, often causing extensive necrosis and loss of teeth. 
The gangrene seldom extends bej^ond the median line in the lips, and the 
tongue usually remains free. In the majority of cases the disease is 
fatal. Death is preceded by symptoms of intense sepsis, with secondary 
septic inflammation of some of the internal organs, especially the intes- 
tines and lungs. In some cases a gangrenous affection of the genital 
organs occurs, which in every respect resembles the affection of the 
cheek. In case recovery takes place, the defect caused by the necrosis 
has to be restored by a plastic operation. 

Hospital Gangrene. — Gangraena nosocomialis, ulcer ative-wound diph- 
therias, only occurs as an infection of wounds, and, as the name hospital 
gangrene indicates, is seldom met with outside of large unsanitary hos- 
pitals. Before wounds were treated antiseptically, it occurred as a fre- 
quent complication after operations or open injuries in most of the Euro- 



196 PRINCIPLES OF SURGERY. 

pean hospitals. It was prevalent among the wounded during the War of 
the Rebellion. Thanks to the labors of Lister and his followers, it has 
now disappeared almost completely among civilized nations. The simple 
fact that this dreadful disease has been almost completely expunged from 
the oldest and most infected hospitals by the antiseptic treatment of 
wounds furnishes conclusive proof of its mycotic origin. Unfortunately, 
practical bacteriology was born too late to take advantage of the numer- 
ous opportunities to study the etiology of this form of wound infection. 
A feature of 'this disease of unusual bacteriological interest is the fact 
that it attacks not only recent wounds, but also wounds covered by 
healthy granulations. A healthy granulating surface is considered as 
a good, if not an absolute, protection against the ordinary pathogenic 
bacteria which infest wounds, but the microbe of hospital gangrene man- 
ifests no such discretion. Whether hospital gangrene is due to a specific 
pathogenic microbe or to exceptional pathogenic power acquired by some 
one of the common bacteria which infest suppurating wounds is not known. 
The latter view is entertained by Sternberg. The first evidence of the ap- 
pearance of hospital gangrene is the formation of a yellowish, pultaceous 
mass upon the surface of a recent wound or upon a granulating surface. 
This mass can be readily wiped away, with the exception of the lowest 
layers, which are firmly attached to the surface. The skin in the imme- 
diate vicinity of this deposit becomes red and inflamed, and is soon dis- 
placed by the same material. The original wound assumes a yellowish-gray 
appearance, and is rapidly enlarged by the extension of the destructive 
process. Within three days to a week the wound is enlarged to double 
its original size. In this, the pulpous, form of the disease extension toward 
the depth of the wound is slow, as fascia and muscles offer considerable 
resistance to its progress in this direction. In the ulcerative form of 
hospital gangrene the wound or granulation surface becomes the seat of 
an ichorous discharge, and the tissues undergo rapid destruction by 
molecular disintegration. The ulcerative form of hospital gangrene 
makes more rapid progress than the pulpous. Although these two forms 
occur as distinct affections throughout, combinations of the two have 
been observed. Hospital gangrene, in preference, attacks small wounds, 
as punctures, the bites of leeches, abrasions, blistered surfaces, etc. 
Many authors have been inclined to believe that diphtheritic inflamma- 
tion of a wound and hospital gangrene are identical, but, so far, no 
positive proof of such identity has been furnished. The clinical course 
of both of these processes is nearly the same, but etiologicall}" and 
pathologically the differences are apparent. Heine claimed that he 
observed hospital gangrene where the wounds were infected with virus 
from patients suffering from genuine diphtheria, and again he saw gen- 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 197 

uine diphtheritic lesions of mucous membranes in patients who were 
exposed to the contagium of hospital gangrene. The general symptoms 
in the beginning of an attack of hospital gangrene are not severe. The 
patient complains of a loss of appetite and a general feeling of malaise. 
In old persons, children, and debilitated subjects, it may prove fatal with- 
out the occurrence of special complications. One of the great dangers 
which attend hospital gangrene, especially the ulcerative form, is second- 
ary haemorrhage. During the pulpy degeneration or molecular disinte- 
gration of the tissues vessels are implicated, and a sudden haemorrhage 
from a large vessel frequently leads to a rapidly-fatal termination. The 
large vessels show an unusual resistance to the destructive effect of 
hospital gangrene, but not infrequently they give way, especially if the 
disease attack a stump after amputation. Septic intoxication is never 
so well marked in hospital gangrene as in diphtheritic affections of 
mucous membranes. Billroth believes that hospital gangrene is caused 
by a specific microorganism which is only reproduced under certain 
atmospheric conditions ; hence the appearance of the disease formerly in 
an epidemic form. Clinical observations leave no doubt that the disease 
is carried from one patient to another by means of sponges, instruments, 
hands, etc. 

Perforating Ulcer of Stomach and Duodenum. — These ulcers follow 
circumscribed necrosis of the wall of the stomach or duodenum, caused 
by a diminished arterial blood-suppty of a limited vascular district. 
That these ulcers are of vascular origin is shown by their shape and 
direct relation to an artery. The defect is in the form of a cone, the 
base being directed toward the lumen of the viscus, and the apex cor- 
responds with a small artery which must have been partially or com- 
pletely obstructed before the necrosis occurred. These ulcers are 
sometimes multiple, and in the stomach they are found in preference 
along the lesser curvature. After interruption of the arterial circula- 
tion the wedge-shaped, ischemic, necrosed portion is removed by the 
action of the gastric juice, and the ulcer is made. As perforating ulcer 
of the stomach or duodenum never occurs in cases of ulcerative endocar- 
ditis, but selects in preference young females, the causes of vascular 
obstruction must be of a local nature. The sphacelus shows molecular 
decay, but no trace of inflammation. Perforating ulcers of the stomach 
and intestines are of interest to the surgeon, because in case of perfora- 
tion their treatment has been brought within the legitimate sphere of 
successful abdominal surgery. The more frequent occurrence of per- 
foration is prevented by circumscribed plastic peritonitis, which seals 
the defect or establishes an adhesion between the affected portion of the 
organ and some other organ. 



198 PRINCIPLES OF SURGERY. 

Perforating Ulcer of Foot. — This ulcer follows a localized necrosis 
of the foot, which is supposed to be, in part, at least, the consequence of 
vasomotor disturbances, to which are added impediments to the circu- 
lation and frequently infection with pathogenic microorganisms. This 
ulcer is remarkable for the regularity of its outline, looking as though a 
piece had been cut out with a punch. The defect corresponds to the 
shape of the detached necrosed tissue. The necrosis affects all of the 
tissues of the part in which it occurs, not even sparing the bones and 
articulations of the foot. The dissections of Duplay, Morat, Fischer, 
and others leave no doubt that this strange ulcer originates from necrosis 
following degeneration of the nerves of the affected region. Infection 
with pus-microbes follows the necrosis, — an occurrence which renders 
the treatment more intractable. 

Ergotine. — One of the effects of chronic ergot intoxication is 
sj^mmetrical dry gangrene. Bread made of flour containing ergot has 
not infrequently occasioned, in Europe, fatal epidemics, usually attended 
with dry gangrene. As before stated, the gangrene following the pro- 
longed administration of this drug is either the result of a chronic 
angiospasm or of a paralj* tic effect of the drug on the peripheral nerves. 

Prognosis. — The prognosis in a case of gangrene should be based 
on the etiology, location, and extent of the disease which caused the gan- 
grene. The existence of complications must also be taken into careful 
consideration. Acute, rapidly-spreading gangrene, irrespective of the 
causes which may produce it, must always be considered as an exceed- 
ingly grave condition. Mycotic progressive gangrene, with and without 
emphysema, unless treated early and heroically, proves fatal almost with- 
out exception, death resulting from septicaemia. Gangrene following 
obliteration of the principal artery of a limb would result in death, in 
the majority of cases, unless a fatal sepsis is prevented by early amputa- 
tion. Necrosis of the entire or greater part of important internal organs 
is incompatible with life from the greatly diminished or completely 
suspended function of the affected organs. The prognosis, so far as life 
is concerned, in cases of senile gangrene, is rendered exceedingly grave 
when the gangrene spreads rapidly, in consequence of an ascending 
arterial thrombosis, or thrombo-phlebitis, and life is in imminent danger 
when the gangrene due to diminished blood-supply is complicated by a 
rapidly-spreading suppurative inflammation, or if septic intoxication 
arise from invasion of the moist necrosed tissue with putrefactive bac- 
teria. The general condition and age of the patient pla} r an important 
part in arriving at correct prognostic conclusions. Patients debilitated 
from antecedent acute or chronic disease are in greater peril of life than 
robust, healthy persons whose circulation and tissue resistance have 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 199 

not been impaired. Infants and the aged succumb to gangrene more 
readily than young adults and persons in middle life, although the gan- 
grene may have resulted from the same causes, reached the same extent, 
and inoculated the same parts. Gangrene of some important organ, as 
the lungs or intestines, is more dangerous to life than peripheral gan- 
grene. The co-existence of complications, such as diabetes, Blight's 
disease, tuberculosis, valvular disease of the heart, and cirrhosis of the 
liver will influence the prognosis correspondingly. 

Treatment. — The prophylactic treatment includes such measures, 
medicinal, dietetic, and otherwise, that are calculated to improve the 
blood-supply of the part threatened with gangrene, and, if this has 
occurred or is inevitable, to prevent putrefaction of the dead tissues. 
In threatened gangrene from obstruction of the main artery of a limb, 
the establishment of collateral circulation must be aided by placing the 
limb in an horizontal or slightly-elevated position, and by the external 
application of dry heat. In the aged suffering from premonitory periph- 
eral symptoms of gangrene, its actual occurrence can often be postponed 
by massage, rubbing the limb from the toes toward the body for ten or 
fifteen minutes twice daily, and by the avoidance of all causes which 
would bring about stasis in the enfeebled blood-vessels. The minutest 
lesions of the skin, as abrasions, corns, bunions, ulcers, etc., should 
receive careful attention in all persons the subjects of a feeble circulation, 
as they frequently are the starting-point of a gangrenous inflammation. 
Diabetic persons are exceedingly liable to be attacked with gangrene 
after the slightest operation or the most insignificant injury, and on this 
account it is advisable to examine the urine before undertaking an 
operation on persons presenting the faintest evidence of this disease. 
As most forms of gangrene are of mycotic origin, all infective atria 
should be protected against infection from without by thorough antiseptic 
precautions. The prevention of decubitus has alread}^ been referred to, 
and here will be only mentioned the necessity of securing for the 
necrosed tissues an aseptic condition by rigid cleanliness and antiseptic 
measures in cases where the necrosis has occurred, or where it cannot be 
prevented. In moist gangrene the prevention of putrefaction is a most 
difficult task. Where gangrene of this type has occurred or is antici- 
pated, the whole surface far beyond the area involved or threatened 
should be rendered aseptic in the same manner as in the preparation for 
an operation, and the parts protected as far as possible against invasion 
with putrefactive bacteria by an absorbent antiseptic dressing. A few 
layers of gauze and a thick compress of salicylated cotton answer an 
excellent purpose in meeting this indication. If gangrene with putre- 
faction has occurred, the etiological indications for local treatment are 



200 PRINCIPLES OF SURGERY. 

best met by multiple incisions through the necrosed tissues and under- 
mined skin and the application of a compress wrung out of a 1-per-cent. 
solution of acetate of aluminum. If the foetor is intense, Labarraque's 
solution of chlorinated soda, properly diluted, answers an admirable 
purpose. In gangrene with partial separation of the slough and 
considerable undermining, permanent irrigation with either of these 
preparations answers the best purpose. All patients suffering from 
gangrene are debilitated from antecedent or concomitant causes, and 
consequently are badly affected by any form of the so-called antiphlo- 
gistic or sedative treatment. Fever is always the result of the entrance 
of septic material, and should therefore not be treated b}' antipyretics, 
but by local measures directed toward the primary cause. Quinine in 
sedative doses does more harm than good. Yeratrum viride, tartar 
emetic, and the innumerable chemical substances which have recently 
been so much lauded as anti-fever remedies should never be prescribed 
in the treatment of fever attending necrosis. The patient's strength 
must be supported from the beginning by a liberal diet and the use of 
stimulants. If the heart's action is feeble, digitalis can be given with 
benefit. Quinine in tonic doses is indicated. Anorexia not dependent 
on high fever calls for some one or a combination of bitter tonics. The 
part affected must be placed at rest and in a position most favorable for 
the passage of the blood through the capillaries. 

The question of removal of gangrenous tissue and the amputation 
of a gangrenous limb should receive thoughtful, conscientious consider- 
ation before an operation is undertaken. The favorable results which 
have followed the operative removal of a gangrenous part after the line 
of demarcation had formed, and the great mortality of operations under- 
taken without such a positive indication, have led many good surgeons 
to advise postponement of all operative procedure until nature has indi- 
cated the site of operation. This conservative rule, however, is incom- 
patible with the teachings of modern surgery. We know that death in 
cases of rapidly-spreading gangrene is caused by septic intoxication. We 
also know that the cause of the septic intoxication inhabits the dead 
tissue, and we are also aware that the extension of the immediate cause 
of gangrene (vessel-obstruction), ascending thrombosis in the arteries, 
and ascending thrombo-phlebitis in the veins proceed from the gangre- 
nous part. In view of these facts, the delay of operative measures in 
the treatment of gangrene until the line of demarcation has been estab- 
lished would be to wait for something which, in the most urgent cases, 
never occurs. In the absence of symptoms indicating danger from 
septicaemia it is not only advisable, but absolutely necessary, to postpone 
the operative removal of the gangrenous part until nature locates the 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 201 

site for the operation by the formation of the line of demarcation. In 
aseptic dry gangrene involving parts where no formal operation is neces- 
sary to secure a favorable healing, later spontaneous elimination should 
be waited for, and after separation of the necrosed tissue the granulating 
surface is treated in the usual manner. In moist gangrene the dead 
tissue is removed as soon as partial separation has taken place by divid- 
ing with scissors the more resistant structures, as fascia and tendons, 
after which the resulting wound is treated upon antiseptic principles. 
In gangrene of the extremities amputation can be done safety, and with 
good prospects of success, as soon as the line of demarcation has 
formed. In such cases it is necessary to remove as little as possible of 
the healthy tissue b} T carrying the incisions in such a manner as to leave 
flaps composed of healthy tissue simply long enough to cover the bone. 
No typical operation should be adopted, as the flaps must be made not 
in conformity with any text-book rules, but the condition of the limb. If 
the patient is febrile, and the character of the fever indicates as its 
origin the gangrenous part, delay, to say the least, is attended by in- 
creased danger of extension of the gangrene, and death from septicaemia. 
Such cases fare best at the hands of prudent but courageous surgeons. 
Procrastination in such cases is a sign of timidity or ignorance. What 
is to be done must be done at once. The patient and friends must be 
made acquainted with the dangers incident to delay, and the only pros- 
pect of recovery by early amputation. Consultation with one or more 
of the neighboring pli3 T sicians is an absolute necessity in such cases. 
Fortified by a fair understanding with the patient and his friends, sup- 
ported by the advice and counsel of one or more of his colleagues, no 
surgeon need fear to follow the dictates of his conscience, even in the 
most unpromising cases. The distinguished Hueter related several cases 
where early amputation saved the lives of patients who were in stupor 
from the effects of septic intoxication to such an extent that an anaes- 
thetic was unnecessaiy. Early amputation should be urged and done 
in all cases where life is placed in jeopard}' from absorption of septic 
material from the gangrenous part. The results after amputation under 
such circumstances will always remain uncertain, because in many in- 
stances fatal general infection occurs soon after the development of the 
first general symptoms, and the local infection frequently extends to the 
site of operation, rendering a recurrence of gangrene in the stump a 
great probabilit}^. Amputation should be done, as near as possible, 
through healthy tissue. Much good judgment is necessary to determine 
this location. It is safe to maintain that, the more acute the attack, the 
more distant should the amputation be made from the apparent boundary- 
line of the gangrene. In gangrene from obstruction of a large blood- 



202 PRINCIPLES OP SURGERY. 

vessel and in gangrene attended by ascending thrombo-phlebitis, arterial 
thrombosis, or both of these conditions, the line of amputation should 
invariably fall through a point where the vessels are patent ; otherwise, a 
recurrence of the disease is almost sure to take place. The concensus 
of opinion of modern surgeons is in favor of amputation for diabetic 
gangrene ; that is, in gangrene of the foot, amputation, as a rule, 
should be made above the knee-joint. Before the amputation is made 
the part to be removed should be enveloped in towels wrung out in 
an antiseptic solution for the purpose of preventing contamination of 
the wound with septic material from the dead tissue. It is almost need- 
less to mention that Esmarch's elastic bandage should never be used, as 
by its application septic material might be forced into the circulation. 
The limb should be rendered as nearly bloodless as possible by holding 
it for a few minutes in a perpendicular position, when an elastic con- 
strictor is applied some distance above the point selected for the ampu- 
tation. In septic patients the parenchymatous oozing sometimes is 
difficult to control, but is managed most successfully by keeping the 
limb in the elevated position, and by making surface-pressure with a 
large, flat sponge or gauze compress wrung out in hot water. As most 
of these patients are prostrated from the effects of the disease, they 
are liable to suffer from shock, and measures should be resorted to 
to prevent this complication, or, at least, diminish its severity. For 
this purpose a subcutaneous injection of t ^q to t §q grain of atropia 
with ^ grain of morphia or ^ grain of strychnia is administered be- 
fore the anaesthetic is diminished. Two ounces of whisky or the same 
amount of brandy should be given at the same time b} r the stomach, 
or, preferably, per rectum. Ether is preferable to chloroform in these 
cases as an anaesthetic. After the operation the most careful after- 
treatment is required to meet possible emergencies. Shock is treated 
by alcoholic stimulants, camphorated oil, musk, strychnia, and coffee. 
If the stomach is irritable, brandy, whisky, or coffee is administered 
by the rectum. Camphorated oil or musk is given lrypodermatically 
every half-hour until the patient reacts. External heat is useful in 
relieving congestions of internal organs and in stimulating the action 
of the heart. Amputation wounds made through tissues that are not 
positively known to be aseptic should always be drained ; this is the 
more necessary if the soft tissues are cedematous. Should the tissues at 
the seat of amputation not present a satisfactory appearance, it is advis- 
able to go up higher, more especially if the vessels are obstructed by a 
thrombus. The fate of the patient is decided within a few days after 
the amputation. The most favorable symptom is a reduction of the 
temperature to normal within a few hours after the operation, which will 



PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 203 

be the case if the fever has been caused by a septic intoxication. With 
the removal of the tissues which furnished the toxic substances and the 
elimination of these through the secretory organs, the septic symptoms 
subside ; and if the patient have enough strength left to carry him over 
the immediate effects of the operation, the prospects of recovery are 
good. If the patient is the subject of a progressive sepsis, the amputa- 
tion, in all probability, will prove powerless as a life-saving measure, as 
the microbes which have reached the circulation reproduce themselves 
with great rapidity, and death from this cause results within a few hours 
to several days. Prompt improvement soon after the operation, with 
recurrence of febrile symptoms in a few days, indicates the occurrence 
of gangrene in the stump. Such symptoms demand a change of dressing. 
If gangrene is present all sutures are removed and a thorough local disin- 
fection practiced, after which the stump should be treated by constant 
irrigation. Re-amputation at this time would, in all probability, prove 
fatal, and reliance on local disinfection, combined with the use of stimu- 
lants and tonics, is advised, with a feeble hope that these measures may 
become the means of limiting the extension of the disease and of sup- 
porting the heart's action until the line of demarcation is established, 
when the surgeon's services are again required to assist nature's efforts 
in the elimination of the dead tissues. In noma and hospital gangrene 
the infected tissues are removed with the sharp spoon, and after thorough 
antiseptic irrigation the actual cautery is applied, and the further man- 
agement of the wound is the same as in case of infected wounds from 
other causes. Chlorinated water and a solution of bromine are excellent 
preparations after the primary disinfection and cauterization in the 
treatment of these diseases. 



CHAPTER VIII. 

Suppuration, 
bacteriological causes and histogenesis of suppuration. 

Suppuration is the most frequent termination of acute inflammation. 
Inflammation terminating in the formation of pus is called suppurative, 
both on account of its etiology and the nature of the inflammatory 
product. Suppuration is the process by which the morphological 
elements of the inflammatory product, the leucocytes, and embryonal 
cells are converted into pus-corpuscles. Suppurative inflammation is 
caused by the action upon the tissues of specific microorganisms, the 
pus-microbes, and the transformation of leucoc} 7 tes and embryonal cells 
into pus-corpuscles is accomplished by the same cause. The brilliant 
results which have been obtained by the antiseptic treatment of wounds 
made it exceedingly probable that all wound-infective diseases are caused 
by living microorganisms. The probability was increased when Koch, 
in 1879, showed the direct connection existing between certain traumatic 
infective diseases in animals and the neA T er-absent definite microorgan- 
isms. It requires no longer any arguments to show, at this time, that 
all inflammatory wound complications, among them suppuration, are, 
without exception, caused by the introduction into the tissues of specific 
pathogenic microbes. Etiologically, most of the purulent processes 
constitute more of a unity than was formerly believed, and the clinical 
varieties are mostly determined by the intensity of the infection, the 
manner of localization, and the degree of resistance possessed b3 r the 
tissues. The most conclusive evidence of the correctness of this asser- 
tion is furnished by the fact that the same streptococcus which produces 
a simple abscess is likewise the most frequent cause of progressive gan- 
grene, and of that most grave form of suppuration, — pyaemia. 

I. HISTORY OF MICROBIC ORIGIN OF SUPPURATION. 

As in the case of nearty all infective diseases, years before the 
specific pus-microbes were discovered living organisms were found in pus 
and described, and were believed to be the essential cause of suppura- 
tion. More than twenty-five 3 r ears ago Klebs discovered, in the tubuli 
uriniferi in cases of p} T elonephritis following suppurative cystitis, between 

(204) 



HISTORY OF MICROBIC ORIGIN OF SUPPURATION. 205 

the pus-cells, small, round cocci, which he believed produced the infection. 
In 1872 the same author published the result of his researches, during the 
Franco-Prussian war, on septic-wound diseases. In this work he again 
referred to the microorganisms which he had previously described, and 
showed that they existed in the tissues and organs — the seat of suppu- 
rative inflammation — before pus had formed. He also showed how these 
microorganisms enter the circulation and become the direct cause of 
pathological conditions in distant organs. Even at that time he placed 
great stress on the fact that, as long as the cocci remained only in the 
tissues at the point of infection, the} 7 produce only local inflammation or 
necrosis, but as soon as the} 7 enter the circulation fever and other s}'mp- 
toms of general septic infection follow. 

Ogston, the discoverer of pus-microbes, published the results of his 
observations and researches in 1881. This patient investigator examined 
the pus of 69 abscesses for microorganisms, and found in 17 of them a 
chain coccus (streptococcus), in 31 cocci ^Yhich arranged themselves in 
groups which resemble a bunch of grapes (staphylococcus), and in 16 
both of these forms were present. In cold abscess he was unable to find 
either of these microorganisms. He also ascertained that these two 
forms of microbes differed in their manner of diffusion in and action on 
the tissues, as the streptococcus, following the lymph-channels and con- 
nective-tissue spaces, was seen to be the cause of diffuse suppurative 
processes, while the staphylococcus was found by him only in abscesses 
which were circumscribed. 

Rosenbach took up the work where Ogston left it, and, as the fruit 
of a number of years of patient study and research, published his 
classical work in 1884 (" Microorganismen bei den Wundinfections 
Krankheiten des Menschen," Wiesbaden, 1884). This work must serve 
as a basis for all future research on suppurative inflammation. Rosen- 
bach availed himself of the advantages offered by an improved technique 
in bacteriological research, cultivated the different pus-microbes upon 
solid nutrient media, and pointed out the difference in the macroscop- 
ical appearances of the cultures of the different kinds of pus-microbes, 
which enabled him to differentiate between them by the naked-eye 
appearances of the cultures upon the different nutrient substances. He 
discovered the staphylococcus pyogenes aureus, the micrococcus p}*o- 
genes tenuis, and three kinds of bacillus saprogenes. 

Passet should be mentioned next in the long list of distinguished 
names of original investigators who have made the bacteriology of 
suppuration a special study. He discovered and described the staphy- 
lococcus citreus and the staphylococcus cereus albus and flavus.and from 
a perirectal abscess he cultivated the bacillus pyogenes fcetidus. The 



206 PRINCIPLES OF SURGERY. 

streptococcus which he found he maintained was different from the one 
described by Rosenbach, as it resembled more closely the streptococcus 
of erysipelas, but this claim has not been substantiated by subsequent 
investigations. The bacillus pyocyaneus was described by Gressard and 
Charrin. The gonococcus, the specific microbe of gonorrhoea, was dis- 
covered by Neisser, in 1879. In our own country the microorganisms 
of pus have been studied b} T such men as Sternberg, Osier, Councilman, 
Welch, Ernst, and Park. 

II. INDIRECT CAUSES OF SUPPURATION. 

Inflammation produces in the tissues conditions which must be 
regarded as indirect causes of suppuration. These conditions favor the 
suppurative process by bringing the histological elements of the inflam- 
matory product in a position or relation to the blood-vessels which 
impairs or suspends their nutrient supply. In acute inflammation the 
connective-tissue spaces become crowded, in a short time, with the 
corpuscular elements of the blood, which, by their presence in such great 
number, cause dilatation of these spaces and pressure upon the adjacent 
capillary vessels, which often result in complete stasis and consequently 
arrest of blood-supply. In consequence of suspended nutrition arising 
from vascular obstruction, the leucocytes undergo coagulation necrosis 
and lose their power of resistance to the action of pathogenic micro- 
organisms. If inflammation attack the fixed tissue-cells with an in- 
tensity short of producing necrosis, the cells proliferate and the 
embryonal cells thus produced constitute another source of histological 
elements of the inflammatory product. If the cells are produced in 
excess of the capacity of the inflamed part to supply them with new 
blood-vessels, the local anaemia thus created places them in the same 
unfavorable condition as the leucocytes in the crowded connective-tissue 
spaces, and they are exposed to the same risk of death from malnutrition. 
If, as the result of rapid tissue proliferation and local ischaemia, the 
embryonal cell become completely detached from the matrix which 
produced it, it is placed in the worst condition, so far as its vitality 
and vegetative capacities are concerned, and it readily succumbs to 
the deleterious action of the pus-microbes. It can be set down as 
a rule that all conditions, local or general, which impair cell nutri- 
tion favor the suppurative process. Suppuration in inflammatory foci 
is always observed first where cell nutrition is most impaired, hence 
in the primaiy inflammatory product among the leucocytes most 
distant from capillary vessels, and among embryonal cells that have 
become isolated or occupy a place most remote from the vascular 
supply. 



DIRECT CAUSES OF SUPPURATION. 207 

III. DIRECT CAUSES OF SUPPURATION. 

Clinical suppuration is caused by the action of pus-microbes on the 
leucocytes and embryonal cells, by which these cells, the morphological 
elements of the inflammatory product, are converted into pus-corpuscles. 
A number of investigators maintain that suppuration can be produced 
artificially in animals by injecting into the tissues certain 

Chemical Pyogenic Substances. — The substances which have been 
found to possess the property of exciting suppurative inflammation are 
metallic mercury, turpentine, and croton-oil. Councilman introduced 
turpentine and croton-oil in aseptic glass capsules into the subcutaneous 
connective tissue of animals under strict antiseptic precautions, and, 
after the wound had healed and the capsules had become encysted, rup- 
tured them subcutaneously. He found that both of these substances 
caused a circumscribed suppuration. Uskoff claimed that a consider- 
able quantity of indifferent substances, such as milk, olive-oil, etc., if 
injected subcutaneously in animals, either at once or by repeating the 
injection from time to time, caused suppuration, and that turpentine 
administered in the same manner always acted as a pyogenic agent. 
Orthmann, under Rosenbach's supervision, repeated Uskoff 's experi- 
ments, and, by resorting to more strict antiseptic precautions, could not 
verify the correctness of his conclusions in reference to the pus-pro- 
ducing properties of indifferent substances. His experiments with croton- 
oil, turpentine, and metallic mercury always resulted in inflammation 
and suppuration. Grawitz and de Bary ascertained that croton-oil, when 
injected in small quantities into the subcutaneous tissues of rabbits, 
caused a serous transudation or a fibrinous exudation, while larger doses 
acted as a caustic, and were only occasionally followed by suppuration. 
If they injected a mixture of pus-microbes and croton-oil it always was 
followed by the formation of pus. They maintained that certain chemi- 
cal substances, used in a definite degree of concentration, injected into 
the subcutaneous tissues of animals, prepared the tissues for the growth 
of the pus-microbes. From a later series of experiments Grawitz 
became more firmly convinced that aseptic turpentine, used in sufficient 
quantities, always causes a suppurative inflammation in the connective 
tissue. Inoculations of different nutrient media with pus produced by 
turpentine showed that it contained no pus-microbes. He also deter- 
mined that such chemical pus had a destructive effect on pus-microbes. 
This action of sterile pus he attributes not to the presence of ptomaines, 
but to the action of its albuminous constituents. His experiments also 
lead to the important observation that when gelatin cultures are over- 
saturated with albumen, or peptone, pus-microbes cease to multiply. 
Yery recently Rosenbach has made a series of experiments which has 



208 PRINCIPLES OF SURGERY. 

convinced him that the chemical pyogenic substances which have been 
mentioned, when injected into the tissues of animals, cause suppuration 
independently of the presence of pus-microbes. Reichel has made nu- 
merous experiments on animals by injecting gradually-increasing doses 
of pus-microbes or their ptomaines into the peritoneal cavity, and has 
proved that a certain degree of immunity is procured, by this treatment, 
to infection with large doses of pus-microbes, which, in other animals 
not thus treated, produced fatal suppurative peritonitis. He maintains 
that suppuration caused by microbes and their chemical products is in 
so far different that the former may produce metastases, while the sup- 
puration caused exclusively by ptomaines always remains local. Buchner 
has recently demonstrated, by experiments, that sterilized cultures of a long 
list of bacteria — seventeen species tested — give rise to suppuration when 
injected into the subcutaneous tissues. The same author has also shown 
that the pyogenic action of these cultures is due to the dead microbes, 
as injections of the clear filtrate yielded only negative results. The tox- 
albumin of staphylococcus aureus killed rabbits and guinea-pigs within 
a few days, and in some cases at the end of twenty-four hours. The 
post-mortem appearances were necrosis or purulent infiltration at the 
point of injection, with external changes which were characteristic of 
inflammation. 

Among those who, from their own experimental work, have come to 
diametrically opposite conclusions can be mentioned Scheuerlen, Ruiys, 
Nathan, and Biondi. 

If we consider for a moment how very difficult it is, in experiment- 
ing on animals with indifferent substances and chemical irritants, to 
procure for the seat of injection a perfectly aseptic condition, it is not 
at all difficult to conceive that opinions still differ in regard to the imme- 
diate and essential cause of suppuration. Taking it for granted that 
certain chemical pyogenic substances, when injected in sufficient quanti- 
ties into the tissues of animals, have the power to produce suppuration, 
inflammation and suppuration produced in such a manner do not repre- 
sent clinically suppurative affections. Neither the inflammation nor the 
suppuration following such experiments are progressive in their charac- 
ter. The chemical substances produce inflammation over an area which 
corresponds with the extent of its diffusion, and the cellular elements of 
the inflammatory product are converted into pus-corpuscles by the 
destructive action of the substance in their protoplasm. The whole 
course of the artificial affection remains aseptic throughout, and the pus 
which is produced is aseptic and sterile, — not clinical, but chemical, 
pus. 

In suppuration, as we see it at the bedside, the direct cause which 



DIRECT CAUSES OF SUPPURATION. 



209 



produced it multiplies in the tissues ; hence its tendency to become pro- 
gressive, and from the pus which is produced the immediate and essential 
cause — the pus-microbes — can be cultivated. Practically, in man, the 
occurrence of suppuration from the action of pj^ogenic chemical sub- 
stances would be possible only on the surface of the body. 

Pus- Microbes. — That the pus-microbes are the immediate and essen- 
tial cause of suppurative inflammation and pus formation has been well 
established by clinical observation and experimentation. Clinical experi- 
ence during the last twenty-four } r ears has shown beyond all doubt that 
suppuration in wounds can be prevented by measures which are calculated 




Fig. 77.— Vertical Section through a Subcutaneous Abscess Caused by 
Inoculation with Staphylococci in the Rabbit, Forty-eight Hours 
after Infection ; Margin toward the Normal Tissue. (Baumgarten.) 



to remove, destroy, and exclude pathogenic microorganisms from with- 
out. 

Rosenbach discovered that, in dogs and rabbits, a small quantity of a 
pure culture of the staph} T lococcus pyogenes aureus injected under the 
skin produced a most violent suppurative inflammation ; cultures of the 
staphylococcus pyogenes albus had the same effect. Cultures of the 
streptococcus pyogenes produced only slight inflammation in rabbits, 
while they proved very fatal in mice. 

Passet procured a pure culture of the staphylococcus pyogenes 
aureus, about the size of a pea, which had been grown upon potato, 
and mixed it with 1 cubic centimetre of distilled water. Of this mixture 
he injected under the skin of a mouse 0.1 cubic centimetre; the animal 
recovered. Another mouse was treated in the same manner, but 0.4 

14 



210 PRINCIPLES OF SURGERY. 

cubic centimetre of a liquefied-gelatin culture was used, and this 
animal died in eighteen hours. Cocci were found in the blood. In rabbits 
and dogs a subcutaneous injection of 1 cubic centimetre of liquid-gela- 
tin culture of the aureus usually produced an abscess at the point of 
inoculation. If the dose was increased to 5 cubic centimetres of the 
same culture the animals died in from eighteen to twenty hours. At 
the same time a local inflammation was found at the site of inoculation. 
In all of the fatal cases the pus-microbe was found in the blood. Of the 
culture of the streptococcus pyogenes it was found necessary to inject a 
considerable quantity in order to produce suppuration. Liquefied-gela- 
tin cultures of the staphylococcus pyogenes aureus and albus, in doses 
of 1 cubic centimetre, injected into the abdominal cavity of rabbits, were 
well tolerated, and death was produced only when the dose was increased 
to from 4 to 6 cubic centimetres. Injection of cultures of the strepto- 
coccus pyogenes into the peritoneal cavity was even better tolerated, 
and usually had to be repeated several times before the animal died of 
septic peritonitis. A needle dipped into a culture of pus-microbes he 
could insert into joints without causing suppuration; but the injection 
of from 0.3 to 0.5 cubic centimetre of a mixture of pus-microbes, sus- 
pended in distilled water, into the hip-joint of rabbits, was followed by 
suppurative arthritis, rupture of the capsule, and diffuse para-articular 
phlegmonous inflammation and suppuration, and often death of the 
animal. Injection of 1 or 2 drops of a liquefied-gelatin culture of the 
staphylococcus pyogenes aureus, or albus, into a vein of a rabbit did not 
produce any serious disturbance; but if the dose was increased to from 
0.5 to 1 cubic centimetre, it, as a rule, caused a fatal disease. In such 
cases multiple suppurating foci were found in the kidney, liver, spleen, 
and lungs, with pleuritis .and peritoneal effusion, pericarditis, and 
myocarditis ; also serous and purulent effusions into joints and muscular 
abscesses. 

The effect of inoculation with pus-microbes in man is the same as in 
animals. Garre made a superficial abrasion on one of his fingers, and 
applied a pure culture of the staphylococcus pyogenes aureus; the only 
symptom observed was a slight redness eighteen to twent3'-four hours 
after the inoculation. He then made three small incisions, and inocu- 
lated himself with a larger quantity of the culture, which was followed 
by superficial suppuration. 

Fehleisen repeated precisely similar experiments upon himself with 
cultures of different kinds of pus-microbes, and, if he succeeded in caus- 
ing suppuration, this was alwa} r s very slight. He also found that minute 
doses, administered subcutaneouslv, were harmless ; while larger doses, 
suspended in water, almost without exception caused abscesses, and, in 



DIRECT CAUSES OF SUPPURATION. 211 

animals, very large doses produced death from sepsis before suppuration 
could take place. Bockkardt introduced a trace of a mixed culture of 
staphylococcus aureus and albus into the cutis of his left fore-finger ; 
after forty-eight hours a small abscess had formed, which was opened, 
and in the pus the same microbes were demonstrated. Bumm injected a 
pure culture of the yellow staphylococcus into the subcutaneous tissue 
of his own arm, and into the arms of two other persons. In each in- 
stance an abscess developed, which varied from the size of a pigeon's 
egg to that of a man's fist, according to the time which elapsed before 
they were opened. In the pus of these abscesses the same pus-microbe 
which had been injected was found. The above observations are con- 
clusive in showing that pus-microbes can be cultivated from the pus of 
every acute abscess, and that, in man and animals, the injection of a 
sufficient quantity of a pure culture into the tissues is followed by sup- 
puration ; and thus far positive proof has been furnished of the direct 
etiological relationship which exists between pus-microbes and suppura- 
tion. Rhine has recently published an account of his experiments, and 
his results are somewhat in conflict with the authorities quoted above. 
He frequently failed to produce suppurative inflammation, even when he 
injected a large quantity of a pure culture, and by repeating the injec- 
tion from time to time. He is of the opinion that, when the absorptive 
capacity of the tissues is not diminished, the pus-microbes are removed 
too rapidly to produce their pathogenic effect. The effect of inoculation 
with pus-microbes will, of course, always vary, according to the quantity 
of the microbes and the local and general susceptibility of the animal 
experimented on. Watson Cheyne has shown most conclusively that 
the number of bacteria introduced greatly modifies not only the intensity 
of the symptoms, but also the character of the disease. His experiments 
were made with cultivations of Hauser's proteus vulgaris. He estimated 
that yV cubic centimetre of an undiluted culture of this microbe con- 
tains 225,000,000 bacteria, and when this quantity was injected into the 
muscular tissue of a rabbit it produced speedy death. A quantity of 
the same culture corresponding with ^ cubic centimetre, administered 
in the same manner, caused an extensive abscess at the point of injection, 
and death of the animal in six or eight weeks. Doses of less than g^ 
cubic centimetre produced no effect, — in fact, doses of less than ^ to T fa 
cubic centimetre, or, in other words, fewer than about 18,000,000 bac- 
teria, seldom caused any positive result. The same author found that in 
the case of the staphylococcus pyogenes aureus it was necessary to 
inject something like 1,000,000,000 cocci into the muscles of rabbits, in 
order to cause a rapidly-fatal result, while 250,000,000 produced a small 
abscess. In the case of the tetanus bacillus, death did not occur in 



212 PRINCIPLES OF SURGERY. 

rabbits when fewer than 1000 bacilli were introduced. He believes, as 
does Rinne, that the action of the preformed ptomaines on the tissues 
modifies the result. It is, therefore, probable that, in the experiments 
in which injection of pus-microbes did not produce suppuration, an 
insufficient number of active microbes were used, and that where indif- 
ferent substances and chemical irritants caused suppuration the implanted 
or injected material was contaminated, or that infection at the point of 
injection occurred through the wound, or subsequently through the cir- 
culation. The latter method of infection should always be borne in 
mind in cases where the presence of an aseptic substance in the tissues 
has apparently been the cause of suppuration. The tissues altered by 
the action of chemical irritants constitute a foreign substance, which 
may determine localization of microbes floating in the circulation, while, 
at the same time, the chemical alterations which they have caused in the 
tissues have prepared a favorable soil for their reproduction. Of late a 
number of pathologists have gone one step farther, and maintain that 
pus-microbes are not the direct cause of suppuration, but that their 
presence is essential for the production of ptomaines, to which they 
attribute pyogenic properties. If certain pyogenic, aseptic, chemical 
substances can convert living cellular elements into pus-corpuscles, as 
has been asserted upon good authority, we should naturally expect that 
chemical substances produced by pus-microbes in inflamed tissue might 
possess the same pathogenic property, and we will briefly consider what 
is known in reference to 

Ptomaines of Pus- Microbes as a Cause of Suppuration. — Grawitz and 
de Bary, after detailing the results of their experiments with injections 
of chemical irritants in their investigations on pus formation, give an 
account of their experiments with the ptomaines of pus-microbes. They 
maintain that these ptomaines, like chemical irritants, prepare the tissues 
for the growth and reproduction of pus-microbes. The action of these 
substances can be studied by injecting sterilized cultures of pus-microbes, 
in which the only active agents could be the preformed toxines. These 
observers injected 4 cubic centimetres of a sterilized culture of the 
staphylococcus pyogenes aureus under the skin of a dog, with the effect 
of causing suppuration. The pus was examined for microbes, but none 
were found. They assert that the presence of oxygen is of the greatest 
importance in the production of ptomaines. Grawitz experimented also 
with a pure preparation of cadaverin, prepared by Brieger from bacteria. 
Cadaverin is a colorless fluid, the chemical formula of which is identical 
with pentamethylendiomin ; a 2j-per-cent. solution of this substance 
destro} r ed the staphylococcus p}^ogenes aureus in an hour, and a small 
quantity added to a culture of pus-microbes arrested further growth. 



DIRECT CAUSES OF SUPPURATION. 213 

A solution absolutely free from microbes, injected under the skin of 
animals, according to strength and quantity used, produced cauterization 
or inflammation, terminating in suppuration or inflammatory oedema, 
followed by resolution and absorption. The pus produced by cadaverin 
contained no bacteria as long as the skin remained intact. The injection 
of a mixture of a solution of cadaverin and pus-microbes was always 
followed by a progressive phlegmonous inflammation. Scheuerlen was 
the first to study the local action of ptomaines on the tissues. He intro- 
duced into the subcutaneous connective tissue of rabbits aseptic glass 
capsules containing sterilized infusion of meat. The wounds healed by 
primary union. As soon as the capsules had become encysted, he broke 
off both ends of the capsule, so as to saturate the tissues in its imme- 
diate vicinity with the fluid it contained. Three to six weeks after 
implantation of the capsule an incision was made down to it, and the 
parts submitted to a thorough examination. The ends of the capsule 
were always found to contain a few drops of thin, yellow pus, which, 
under the microscope, showed all the characteristic appearances of that 
fluid. No inflammation of the surrounding tissues. Cultivation experi- 
ments with the pus yielded negative results. It is evident that suppura- 
tion in these instances was caused by the action of the preformed 
ptomaines on the leucoc}^tes and embryonal cells, and that its extension 
did not occur because the cause did not multiply in the tissues. In 
about twenty experiments the pus was found only inside of the cap- 
sule. Weigert has repeatedly shown that the difference between a 
purulent and fibrinous exudation can be readily demonstrated, as the 
former does not coagulate, although white corpuscles and plasma may be 
present. 

Klemperer believes that this difference is due to previous destruction 
of fibrogen in the pus by the pus-microbes. The putrid-meat infusion 
used by Scheuerlen caused limited suppuration, and on that account it 
must also have possessed the property to prevent coagulation. To prove 
this he made the following experiment : The abdomen of a rabbit was 
opened while the animal was under the influence of chloroform, and 
blood was drawn directly from the aorta into a glass tube containing 
putrid extract of meat. As the fluids gradually became mixed the blood 
assumed a brownish-red color ; coagulation did not occur for hours and 
days, while in the control experiments, with solution of salt, the blood 
coagulated firmly after the lapse of a few minutes. He next made thirty 
cultures of the staphylococcus pyogenes aureus upon agar-agar gelatin, 
and the same number of cultures of the albus, and after completion of 
their growth, fourteen days later, he sterilized them with boiling water, 
and, after shaking the fluid, removed the cultures and boiled them for a 



214 PRINCIPLES OF SURGERY. 

few minutes, and finally filtered them ; he thus obtained about 150 cubic 
centimetres of a light-yellow fluid. This was reduced to 8 cubic centi- 
metres by boiling ■ before using, the fluid was again filtered. The filtrate 
was put in capsules, and after sealing their ends hermetically they were 
inserted into the subcutaneous connective tissue of animals with the 
same care as in the preceding experiments. The suppuration which 
followed the breaking of the glass capsule in these cases was again found 
to be limited to the space within the capsule, being caused by action of 
the preformed ptomaines on leucocytes and embryonal cells, which found 
their way into the interior of the glass capsule. 

The cadaverin and putrescin, two ptomaines prepared by Brieger, 
were next experimented with in the same manner. In preventing coagu- 
lation the results were even more striking than with the former sub- 
stances. These experiments leave no doubt that ptomaines derived from 
P3>-ogenic bacteria produce a chemical action on leucocytes and embrj^onal 
cells by which they are converted into pus-corpuscles. The suppuration 
thus produced, however, never extends beyond the tissues which are 
brought in contact with them, and, therefore, always remains circum- 
scribed. In this respect the results of the experiments just cited do not 
correspond with suppuration as we observe it in practice, as here from 
the same causes, and apparently often under the same conditions, the 
process presents the greatest possible variations in reference to its intensity 
and extent. In one case the suppuration remains circumscribed, result- 
ing in a furuncle ; in others the regional infection is more extensive, and 
a diffuse, phlegmonous inflammation is the result; while in the third class 
the local infection leads to general systemic invasion, and the patient dies 
of sepsis or pysemia. The clinical form of suppuration is noted for the 
progressive character of the infection, which is due to the reproduction 
of pus-microbes in the tissues and the production of ptomaines pro- 
portionate in amount to the number of microbes present, and, perhaps, 
also modified to a certain extent by the character of the soil. Practi- 
cally, the matter remains the same as before it was known that the 
ptomaines produced in the tissues bjr the pyogenic microorganisms 
could cause suppuration, as pus-microbes must be introduced into the 
organism, where they must also find an appropriate soil for their repro- 
duction, before ptomaines can be produced in sufficient quantity to 
account for the occurrence of the clinical forms of suppuration. To the 
practical surgeon it is immaterial to know whether the transformation 
of leucocytes and embryonal cells is brought about by the direct action 
of pus-microbes or by the ptomaines which they produce in the tissues. 

Description and Specific Action of the Different Pus-Microbes.— The 
microbes which, when present in sufficient number in the tissues, excite 



DIRECT CAUSES OF SUPPURATION. 215 

suppurative inflammation are called pus-microbes. Their effect on the 
cellular elements of the inflammatoiy product is a specific one, convert- 
ing them into pus-corpuscles. Only such microbes will be described here 
which have been cultivated from pus, and the specific action of which 
has been demonstrated experimentally. 

1. Staphylococcus Pyogenes Aureus. — The yellow staphylococcus is 
the microbe most frequently present in acute abscesses. Under the 
microscope it cannot be distinguished from the staplrylococcus pyogenes 
albus. 

It is easily cultivated upon gelatin, agar-agar, coagulated blood- 
serum, and potato. The culture liquefies gelatin. It grows best at a 
temperature approaching that of the blood, but can be cultivated at 
30° C. It peptonizes albumen and coagulates milk. The culture grows 
in the track of the needle and upon the surface of the nutrient medium. 
The gold-yellow color of the culture appears only if the colony is ex- 
posed to atmospheric air. Cultures upon gelatin or agar-agar retain 
their virulence for a year or more. This coccus is met | 

with frequently in acute circumscribed abscesses, osteo- °%$!°gp 2 
myelitis, pyaemia, and ulcerative endocarditis. |p? $* 

2. Staphylococcus Pyogenes Albus. — This pus- t^i& 4$$& 
microbe can be distinguished from the yellow coccus fig. 78. — Micro- 
only by the color of the culture, which is white. Both of°stapSSoSk? 
Passet and Klebs have observed in the white culture of CJJS - (Rosenbach.) 

1, culture twenty-four 

this coccus small yellow dots, which, when isolated, hours ; 2, culture two 

*) 1 ' 1 months. 

lost their color. These authors, therefore, consider 
the yellow and white staphylococcus as varieties of the same kind of 
pus-microbes. As other experimenters have not been able to verify 
these observations, we must take it for granted that the staphylococcus 
pyogenes albus differs from the aureus in that it possesses no power 
to produce the same yellow color which characterizes the culture of the 
latter. Its pathogenic properties, both in man and animals, are some- 
what less than those of the aureus. Passet claims that the white coccus 
is more frequently found in the suppurative lesions in man than the 
yellow, while Rosenbach makes a contrary assertion. The latter author 
seldom found it alone in pus, but more frequently associated with the 
aureus. The cultures of both the yellow and white staphylococcus upon 
gelatin present an irregular surface, and the margins are dotted with 
minute globular projections. Both of these microbes liquef}^ gelatin, 
but agar-agar and coagulated blood-serum are not similarly affected. 

3. Staphylococcus Pyogenes Citreus. — Found by Passet in about 10 
per cent, of acute abscesses examined. Like the aureus and albus, it 
liquefies gelatin. Cocci singly, or in pairs, or zodglcea. If cultivated 



216 PRINCIPLES OF SURGERY. 

on nutrient gelatin, or agar-agar, a sulphur or lemon-yellow growth 
develops after twenty-four hours, which at that time resembles the 
aureus, but later does not change into a gold-yellow color. Like the 
aureus, pigmentation only takes place if the culture is exposed to air. 
According to Passet, its virulence is somewhat less than that of the aureus 
andalbus. This statement has been confirmed by Cheyne. When a cul- 
ture of this pus-microbe is injected under the skin of mice, guinea-pigs, or 
rabbits, an abscess forms, from the pus of which a culture of the same 
lemon color can be obtained. 

4. Staphylococcus Cereus Albus. — This microbe was first discovered 
by Passet in the pus of a periosteal abscess of a finger, as well as in an 
abscess of the heel. A culture upon gelatin is distinguished from that 
of other pus-microbes upon the same nutrient medium by its forming a 
white, slightly-shining layer, like drops of white wax, with a somewhat 
thickened, irregular edge. The needle-stab develops into a grayish- 
white, granular thread. In plate cultivations, on the first day, white 
points are observed, which spread themselves out on the surface to spots 
one-half a millimetre in diameter; when cultivated on blood-serum, a 
grayish- white, slightly-shining streak develops ; and on potato the cocci 
form a layer which is similarly colored. This microbe is not pathogenic 
in rabbits. 

5. Staphylococcus Cereus Flavus. — Passet cultivated this microbe 
from the pus of a case of chronic periostitis of the tibia. If cultivated 
on gelatin, the growth, which is at first white, becomes of a citron- 
yellow color, resembling somewhat yellow wax, considerably darker than 
the culture of staplr^lococcus pyogenes citreus. Both varieties of 
staphylococcus cereus are very rarely met with in abscesses, and inocula- 
tion experiments with them have usually proved harmless. Baumgarten 
thinks it possible that in cases where they were found in abscesses they 
were not the cause of suppuration, but occurred as an accidental inva- 
sion after the pyogenic microbes had disappeared. 

6. Staphylococcus Flavescens. — This microbe was found in an 
abscess by Babes, and occupies an intermediate position between the 
stapl^lococcus pyogenes aureus and albus. On gelatin, the growth 
forms a colorless kyer and causes liquefaction. It is fatal to mice, 
sometimes causing abscesses, and, in large doses, septicaemia. 

Welch described, a few years ago, a white staphylococcus which he 
found constantly upon and in the skin, which he called staphylococcus 
epidermidis albus. To this microbe he attributes the frequent occurrence 
of stitch-abscesses after operations during which the ordinaiy strict 
antiseptic precautions are carried out. It is more than probable that 
this microbe is the ordinary staphylococcus p} r ogenes albus. 



DIRECT CAUSES OF SUPPURATION. 217 

7. Micrococcus Pyogenes Tenuis. — Rosenbach found this micro- 
organism in a large abscess which had given rise to no general symptoms. 
It is of rare occurrence. On agar-agar it forms an exceedingly delicate, 
almost invisible, white film. The individual cocci are irregular in shape 
and larger than the staphylococci. 

In all cases in which this microbe is the sole bacterial cause of sup- 
puration, the process appears to have been unattended by any very severe 
inflammatory symptoms and little or no general febrile disturbances. 
This microbe was not found by an} r one else but Rosenbach until Februaiy, 
1888, when Raskina isolated it from the pus and organs in a case of scar- 
latina complicated with pyaemia, which resulted fatalty on the eighteenth 
day after the beginning of the primary disease. At the necropsy mul- 
tiple miliary abscesses were found in the kidnej's, at the junction of the 
cortex with the medullary portion. From the pus of these abscesses a 
pure culture of the micrococcus was obtained. Inoculation experiments 
made on rabbits gave only negative results, even though the coccus was 






Fig. 79.— Micrococcus Pyogenes Tenuis. Fig. 80.— Microscopic Picture of Strep- 
Cultivated from Pus in a Case of tococcus Pyogenes. (Rosenbach.) 
Empyema. (Rosenbach.) 

present in the blood twent3 r -four hours after inoculation ; hence it is 
problematical as to its being a pyogenic microbe. Like the staphylo- 
coccus cereus, it probabl}* belongs to the so-called metabiotic microbes 
of Garre, occurring secondarily after suppuration has been established 
by genuine pyogenic microbes. 

8. Streptococcus Pyogenes. — Cocci, somewhat larger than staphy- 
lococci, always divide transversely ; so that they arrange themselves in 
the form of chains, which are usually more or less curved. 

The cocci also appear singly or as diplococci. Cultures grow very 
slowly on ordinary nutrient media at summer temperature, but with 
great rapidity at the temperature of the body. Cultivated in a streak 
on the surface of gelatin on a glass plate, this microbe forms at first 
whitish, somewhat transparent, rounded spots, of the size of small grains 
of sand. On agar-agar it grows most luxuriantly at a temperature of 
35° to 3t° C. Even if the inoculation is made with the point of a 
needle in a continuous line, the culture appears in isolated, small points. 
In its further growth the culture is elevated in the centre, and presents 







3f 


\ 


\ 


s 




• 

••• 



218 



PRINCIPLES OF SURGERY. 



a pale, brownish color ; while the periphery is flattened, except at the 
extreme margin, which is again raised, and often with a spotted appear- 
ance. Still later, the periphery develops successive la3 T ers or terraces, 
which were pointed out by Rosenbach as characteristic macroscopical 
features of the cultures of this microbe upon solid nutrient media. The 
growth is so slow that in two or three weeks the maximum width of the 
culture streak is about 2 or 3 millimetres. In a vacuum the strepto- 
coccus effects peptonization of albumen and beef. Subcutaneous inocu- 
lation in mice yields negative results in about 80 per cent. ; sometimes 
a slight suppuration follows at the seat of puncture ; at times the animal 
dies without showing any particular pathological lesions, and no micro- 
organisms can be found in any of the internal organs. In the subcu- 
taneous tissue of rabbits in small quantities they cause hyperemia, red- 
ness, and slight swelling, which disappears in the course of two or three 
days; when larger quantities are used, some authors claim that they 
produce small circumscribed abscesses. In healthy rabbits intra-venous 
injection of even a pure culture of the streptococcus causes no serious 







3l8kih,Z 



4p? 'I 1 



flftfi' 



9+M 



Fig. 81.— Bacillus Pyogenes Fcetidus. 
X 790. (Muegge.) 



Fig. 82.— Bacillus Pyocyaneus. 
(Fluegge.) 



X700. 



symptoms. If the animals are debilitated previously by injections of 
toxic substances, death is caused by rapid reproduction of the microbe 
in the tissues. If a pure culture is injected into a serous cavitj', it 
causes, first, inflammation, and, later, effusion, which is again absorbed. 
In the pus from the human subject the streptococcus is found in about 
40 to 60 per cent, of the specimens examined. This pus-microbe invades 
the tissues far in advance of suppuration. It is found most frequently 
in inflammations following the lymphatic channels. It is also found in 
grave affections, in progressive gangrene. In several cases of pyaemia 
cultures of the pus yielded a growth composed exclusively of the 
streptococcus. 

9. Bacillus Pyogenes Fcetidus. — Passet found this microorganism 
in the pus of a perirectal abscess. This bacillus possesses slow motion, 
its ends are rounded, and in cultures appears usually in pairs. 

In stained specimens each bacillus shows in its interior one or two 
spores. This bacillus grows on gelatin, forming a delicate white or 
grayish layer on the surface, but causes no liquefaction. When culti- 



DIRECT CAUSES OF SUPPURATION. 219 

vated on agar-agar and potato it has the appearance of a light-brown, 
glistening layer, which emits a very offensive odor. In mice traces of 
the culture do no harm ; the injection of several drops causes septicaemia. 
Injection of about 10 minims of the culture into guinea-pigs causes an 
abscess, in which the bacilli alone are found as pyogenic cause; direct 
intra-venous injection causes sepsis. 

10. Bacillus Pyocyaneus. — It has been known for a long time that 
the greenish-blue color of the pus, occasionally found in the pus of sup- 
purating wounds, is due to the presence of a color-producing microbe. 
The investigations of Gessard and Charrin, Ernst, Fordos, and Ledder- 
hose have shown that this chromogenic microbe is the bacillus pyocy- 
aneus. Freudenreich found, as a result of his numerous experiments, 
that the bacillus pyocyaneus causes a change in bouillon which renders it 
unfit for the growth of other species. In the pus and on solid culture 
media the bacilli appear in pairs, small groups, or, what is more common, 
large masses, or zooglcea. 

This bacillus grows upon gelatin, which liquefies and is stained a 



iv %" 




Fig. 83.— Bacillus Pyocyaneus. X 700. 

greenish blue. It also grows vigorously on agar-agar and potato, both 
of these substances being stained a greenish hue. In milk it causes 
caseation, with subsequent peptonization of the casein and simultaneous 
appearance of ammonia, while the coloring material appears on the 
surface in the form of greenish-yellow spots. Fordos and Gessard 
isolated the coloring material which this bacillus produces, and called 
it pyocyanin. It is soluble in chloroform, and from a pure solution 
crystallizes in long, blue needles. Gessard found that a temperature of 
57° C, maintained for five minutes, destroyed the power of the bacillus 
pyocyaneus to produce pigment without destroying the vitality of the 
bacillus, which was propagated through successive cultures without 
regaining this power. 

Fluegge asserts that this bacillus is devoid of pyogenic properties, 
and appears only as a harmless settler upon wounds. Ledderhose, by 
cultivating this bacillus upon a large scale, obtained a considerable 
quantity of p} r oc3^anin, and by chemical analysis determined its formula 
to be C 14 H 14 , N 2 C. In doses of 1 gramme, as muriate of pyocyanin, 



220 



PRINCIPLES OF SURGERY. 



injected into the circulation of different animals, he observed no toxic 
s}'mptoms. When a pure culture of the bacilli was injected, he produced 
suppurative inflammation, and attributes this result not to the presence 
of pyoeyanin, but to other as yet unknown phlogistic and pyogenic 
substances elaborated by the bacillus in the tissues. 







f§ 



Fig. 84.— Gonococcus, after Buutm. 



II. Micrococcus Gonorrhoeas. — The micrococcus of gonorrhoea, also 
called gonococcus, was discovered by Neisser in 1879, who also demon- 
strated the etiological relationship between this microbe and gonorrhoea. 
Bumm first succeeded in cultivating it upon artificial nutrient media 




Fig. 85.— Gonorrheal Pus. 

and made a special study of its morphology and pathogenesis. The 
gonococcus alwa}^s occurs in pairs, and is, therefore, a diplococcus. 

The cocci appear as hemispherical bodies with their flattened sur- 
faces in apposition, which imparts to the microbe the characteristic 
biscuit-shaped appearance. The gonococci are found in clusters or 
clumps upon or — what is more probable, as Bumm asserts — within the 



DIRECT CAUSES OF SUPPURATION. 



221 



pus-corpuscles of gonorrhoea! pus. The microbes within the corpuscle 
may become so numerous as to fill the entire space with the exception 
of the nucleus. 

The mucous membrane of the urethra and the conjunctiva are the 
localities most predisposed to the pathogenic action of the gonococcus. 
The gonorrhceal inflammation, which is at first superficial, penetrates 
more deeply into the mucous membrane with the advancing gonococci, 
which invade the epithelial cells. 




Fig. 86.— Gonorrhceal Conjunctivitis, Second Day of Sickness, after Bumm. 

Section through the mucous membrane of upper eyelid ; invasion of the epithelial layer by gonococci. 

Bumm, Bockhardt, and others have reported cases of mixed gonor- 
rhceal infection in which pus-microbes, acting upon tissues altered by the 
gonorrhceal inflammation, gave rise to abscesses in the glands of Bartholin, 
to cystitis, pelvic cellulitis, and suppurative synovitis. Suppuration in 
joints, peritoneum, and connective tissue the seat of gonorrhceal infection 
is prone to occur in the course of secondary infection with more potent 
pyogenic microbes. 

12. Bacillus Coli Communis. — This microbe was first discovered by 
Emmerich, in 1885, in the blood, various organs, and the dejections of 



i 






Fig. 87.— Baclli/us Coli Communis. 



cholera patients at Naples. A year later Escherich showed that it is 
constant^' present in the alvine discharges of health}* persons. It is a 
short and thick bacillus (Fig. 87) with rounded ends ; the prevailing form 
in culture is a short oval. The bacilli are frequentty united in pairs. It 
stains readily with aniline dyes, but is decolorized promptly when 
treated with a solution of iodine. It is an aerobic and facultative anae- 
robic, non-liquefying bacillus. It is non-motile, and does not multiply 



222 



PRINCIPLES OF SURGERY. 



by spores. It grows readily in various culture media. In gelatin-stick 
cultures the growth ou the surface is rather diy and thin ; in old cultures 
it covers the entire surface. 

The bacillus coli communis is the most frequent cause of intestinal 
sepsis. It is constantly present in the appendix vermiformis, and is the 
most fruitful source of the different forms of acute and chronic inflam- 
mation of this organ. As this bacillus gains entrance under favorable 
conditions into the different ducts and glands in communication with the 
intestinal canal, it is often the direct cause of suppurative inflammation 
in organs in direct connection or close contact with the intestinal tract, 
— notabl}^ the liver and biliary passages. The p} T ogenic properties of 
this microbe have been quite recently studied with great care, and pure 





Fig. 



(Koch.) 



1, 'white corpuscles from normal blood ; 2, pus-corpuscles with cocci in their interior ; 
3, pus-corpuscles, with bacilli in their interior. 



cultures have been obtained from abscesses remote from the intestinal 
tract, which proves that it retains its specific pathogenic properties after 
its entrance into the tissues. 

IV. PUS. 

Pus is the liquefied product of suppurative inflammation. It can 
be defined as a dead or dying tissue composed of cells with a fluid inter- 
cellular substance. Pus is an opaque, creamy, 3'ellowish-white or 
greenish-white fluid, which, in a recent state, shows a slightly-acid re- 
action, and, later, becomes alkaline by the formation of ammonia. If it 
is of a yellowish color, creamy consistence, and odorless, it is the pus 
bonum vel laudabile of the old authors. If it is thin and intimately 
mixed with blood it is called sanious or ichorous pus. If it contain but 



pus. 223 

few pus-corpuscles and resemble serum, we speak of serous pus. Pus 
undergoing putrefaction from the presence of saprophytic bacteria is 
rendered fetid, and is then termed fetid pus. Pus mixed with the 
products of tubercular inflammation is designated tubercular pus, and 
if mixed with the secretion of an inflamed mucous membrane it is defined 
as muco-pus. If pus is allowed to stand undisturbed for a number of 
hours in a test-tube, it separates into two parts ; the upper, the liquid 
portion, is the pus-serum, or liquor puris, while the lower represents the 
solid constituents of the pus, the pas-corpuscles. 

Pus-serum. — The pus-serum contains albumen, a compound called 
pyine, regarded by Mulder as identical with tritoxide of protein, occa- 
sionally chondrin, glutin, and leucin, abundant fatty matter, and inor- 
ganic substances similar to those dissolved in the liquor sanguinis. 
Pus-serum contains no oxygen or hydrogen, or if present these gases are 
found only in minute quantities. On the other hand, it contains nitro- 
gen and carbonic acid in large amounts. It contains more potash and 
soda than blood-serum. Among the albuminous substances which it 
contains are paraglobin, albuminate of potash, serum, albumen, and my- 
osin. Pus-serum, in fact, is liquor sanguinis plus soluble compounds 
which have developed during the inflammatory process ; hence it contains 
in solution the ptomaines elaborated by the pus-microbes. 

Pus-corpuscles. — The histological sources of pus-corpuscles are the 
leucocytes and embryonal cells. In acute inflammation the process is so 
rapid that the pus-corpuscles are derived almost exclusively from leuco- 
cytes. The conversion of a leucocyte into a pus -corpuscle in clinical 
suppuration is invariably accomplished hy one or more kinds of pus- 
microbes, which have been described. The pus-microbes constitute the 
most important morphological element of the product of suppurative 
inflammation, being not only diffused between the cells, but also finding 
their way into the interior of the cells. 

All pus-corpuscles show structural changes which indicate disinte- 
gration. The leucocytes present, as the first evidence of transformation 
into pus-corpuscles, fragmentation of the nucleus. 

Nuclear fragmentation is an entirely different process from karyo- 
kinesis, as it is not, like the latter, an indication of cell reproduction, but 
of cell destruction. The nucleus breaks up into two to six or more 
fragments, the cell-body still retaining its original form. Fragmenta- 
tion of the nucleus is attended by other forms of intra-cellnlar disinte- 
gration. The protoplasmic strings, which form a living reticulum in the 
interior of the nucleus and cell-body, break up and disintegrate. The 
embryonal cells which are converted into pus-corpuscles undergo 
similar retrograde changes as have been described in the leucocyte. 



224 



PRINCIPLES OF SURGERY. 



Pus-corpuscles are not always of the same size and shape. Their size 
depends on their histological source. Those derived from leucocytes are 
somewhat uniform in size, while in subacute and chronic suppuration 
the fixed tissue-cells in a state of proliferation furnish a large percentage 
of the pus-corpuscles, and consequently their size varies according to the 
tissue-cells which undergo this change. As long as the leucoc3 T tes or 
embryonal tissue-cells are not completely destroyed by the pus-microbes 
or their ptomaines., thejr vary greatly in their shape. The variation in 
shape in fresh pus-corpuscles which have not completely succumbed to 
the pus-microbes is due to their amoeboid movements. If pus from an 



?^x %S^k. 




<ni life 



~, V 






j=: : V"::... 









^'.■■■■■° 




Fig. 89.— Fragmentation of Nucleus in Leucocytes undergoing Transformation 
into Pus-coRPUSCiiES. Hartn. 8, Oc. iv. {Lander er.) 



acute abscess is examined in a moist chamber upon a warm slide, the 
amoeboid movements of the pus-corpuscles can be observed for hours, 
provided the slide is kept at a proper temperature. 

Pus-corpuscles subjected to the action of acetic acid clear up and 
show their fragmented nucleus much plainer. If pus-corpuscles are 
mixed with water they become larger and hydropic from imbibition of 
fluids. The round pus-corpuscles, according to Recklinghausen, are 
dead leucoc3^tes or embryonal cells which have lost their amoeboid move- 
ments. Liquor potassa dissolves the pus-corpuscles, and, if added to 
fluids containing pus, changes them into a gelatinous mass. In chronic 



PUS. 



225 



abscesses the pus-corpuscles undergo molecular degeneration, and such 
pus under the microscope shows no well-formed corpuscles, but a mass 
of granular detritus. If the serum is absorbed, we speak of inspissation 
of pus. If a wall of cicatricial tissue form around a collection of pus, 
we say that the pus has become encysted or encapsulated. 











Fig. 90.— Pus with Staphylococcus. 
X 800. {Fluegge.) 







"""/#' "■"•'''.•• ■ -''* **• v .i'-^.,. 






«•■>■ 



Fig. 91.— Pus with Streptococcus. 



Blue Pus. — Blue pus is produced by the bacillus pyocyaneus, — a 
comparatively mild pus-microbe possessing chromogenic properties. The 
coloring material is imparted to pure cultures and the dressings used in 
the treatment of suppurating wounds in which this microorganism is the 
principal cause of suppuration. 

2 3 4. 



:©; 





Fig. 92. (Billroth- Winiwarter.) X 400. 

1, dead pus-corpuscles: 2, various forms which living pus-corpuscles assume by their amoeboid movements ; 
3, pus-corpuscles acted upou by acetic acid ; 4, pus-corpuscles after addition of water. 

Red Pus. — Red pus has recently been described b} r Ferchmin. It is 
caused by a chromogenic bacillus whose length is about one-third of the 
diameter of a red blood-corpuscle. The bacillus is non-motile and color- 
less, but is readity stained b} T Gram's method. It can best be cultivated 
upon blood-serum ; the cultures have a bright-red color, which later 
changes to violet. 



15 



CHAPTER IX. 

Suppuration {continued). 

CLINICAL FORMS OF SUPPURATION. 

In reference to the time required to transform the product of inflam- 
mation into pus, suppuration can be divided into acute, subacute, and 
chronic. 

I. Acute Suppuration. — In acute suppuration the wall of the capillary 
vessels is altered so seriously that emigration of the colorless corpuscles 
takes place with such rapidity that within a few hours the connective- 
tissue spaces are crowded with them, and in a few days the inflammatory 
swelling presents indications of approaching suppuration. The inflam- 
matory product is hard to the touch, and the tissues around it become 
oedematous from obstruction to the plasma circulation within and in the 
immediate vicinity of the inflamed tissues. The hardness of the swell- 
ing is due to the infiltration of the connective tissue with leucocytes. In 
this form of suppuration a central ischemic area is established hy the 
rapid accumulation of leucoc3<tes in the connective-tissue spaces and by 
pressure upon the inflamed and weakened capillary vessels, which finally 
leads to complete stasis. The pus-microbes and preformed ptomaines 
are present in such large quantities that liquefaction of the inflammatory 
product takes place within a few daj-s. The first appearances of suppu- 
ration are observed among the cellular elements which appeared first, 
which corresponds to a point in the centre of the inflammatory swelling, 
because at this point tissue nutrition has suffered most, and the inflam- 
matory product has been exposed longest to the deleterious influences 
of the pus-microbes and their toxins. The direct causes of conver- 
sion of leucocytes into pus-corpuscles are the pus-microbes and their 
toxins, the pathogenic action of which on the tissues results in puru- 
lent liquefaction of the inflammatory product. Softening in the centre 
of an inflaminatoiy swelling is almost an unerring sign of approaching 
suppuration. The central suppurating focus increases in size 1>3 T the ex- 
tension of the process of liquefaction in all directions, the leucocytes 
saturated with the toxins of the pus-microbes being rapidly transformed 
into pus corpuscles. Acute suppuration is always accompanied by more 
or less necrosis of the fixed tissue-ceils. The acute cell necrosis is the 

(226) 



CLINICAL FORMS OF SUPPURATION. 227 

result of diminished blood-supply and the local toxic effect of the chemical 
products of the pus-microbes. Necrosis occurring so constantly from 
the combined action of these two etiological factors in acute suppura- 
tive osteomyelitis furnishes a good illustration of this. In phlegmonous 
inflammation, from the smallest furuncle to the largest acute abscess, 
connective-tissue necrosis is a constant occurrence, following as an un- 
avoidable sequence of acute suppuration. Acute suppuration is almost 
without exception attended by a complexus of symptoms, indicating the 
entrance of phlogistic substances from the inflamed tissues into the 
general circulation, such as fever, headache, thirst, loss of appetite, which 
usually subside with the removal of the primary cause. Acute osteo- 
myelitis, acute suppurative inflammation of the large serous cavities and 
joints, and phlegmonous inflammation of different organs are excellent ex- 
amples of what is understood by acute suppuration, from an etiological, 
pathological, and clinical stand-point. 

2. Subacute Suppuration. — As acute inflammation may pass into a 
subacute form, so suppuration may be dekyed in acute inflammation for 
days and weeks, if the indirect and direct causes which are concerned in 
the transformation of the cellular elements into pus-corpuscles are present, 
less in degree and intensity than in acute suppuration. The character 
and intensity of the primary microbic cause may determine a subacute 
type of inflammation from the beginning, and suppuration is correspond- 
ingly delayed. In subacute suppuration the tissues have more time to 
accommodate themselves to the presence of the inflammatory exudate, 
and hence tissue necrosis is a less constant occurrence, and, if present, 
it is less extensive. In subacute suppuration, at least, a part of the pus- 
corpuscles are derived from the fixed tissue-cells ; while in acute suppu- 
ration central liquefaction of the inflammatory product often takes place 
within three or four days, the same stage in the subacute form is often 
not attained in as many weeks. As a rule, the general symptoms are 
also less severe. 

3. Chronic Suppuration. — In acute and subacute suppuration the pus- 
corpuscles are derived, in the former almost exclusively, and in the latter 
largely, from the extravasated leucocytes. With few exceptions chronic 
suppuration occurs as the result of infection with pus-microbes of a pre- 
existing pathological product composed of granulation tissue. In such 
cases the embryonal tissue is the product of a specific inflammation 
caused by the presence of microorganisms which possess no pyogenic 
properties, but which excite in the tissues a chronic inflammation, the 
product of which consists of granulation tissue. The bacillus of tuber- 
culosis, the microbe of syphilis, and the actinomyces are good illustra- 
tions of this class of microbes. If a lesion caused by any of these 



228 PRINCIPLES OF SURGERY. 

microbes become the seat of infection with pus-microbes, the latter and 
their toxins are brought in contact with cells which are readily con- 
verted into pus-corpuscles. In chronic suppuration the pus-corpuscles 
are derived mostly from embryonal cells, and consequently they show a 
greater variety in size and shape than the pus-corpuscles found in an 
acute abscess. Purulent liquefaction of a mass of granulation tissue is 
the characteristic pathological feature of chronic suppuration. Embry- 
onal cells derived from any of the fixed tissue-cells are converted into 
pus-corpuscles by the pus-microbes and their toxins in the same 
manner as the leucocytes in an acute abscess, only that this result is 
attained more slowly. In the majority of cases chronic suppuration is 
the result of infection with pus-microbes of a pre-existing granulating 
focus, the liquefied portion of which constitutes the contents of the 
chronic abscess. While an acute abscess is often developed in the course 
of a few days, and a subacute in as many weeks, it may require as many 
months or years for the products of a specific inflammation to be trans- 
formed into a chronic abscess. 

Suppuration in Wounds. — Infection of a recent wound with a suffi- 
cient number of pus-microbes is followed by suppurative inflammation, 
which in its local and general manifestations resembles phlegmonous 
inflammation as it occurs without a wound. One of the earliest evi- 
dences that such infection has taken place is a profuse primary wound- 
secretion. This secretion is a mixture of blood and serum, and is 
secreted in excess on account of the inflamed capillaries being more 
permeable, and yielding more readily to the intra-vascular pressure. It 
is also possible that under these circumstances closure of the lumen of 
divided capillary vessels does not take place as promptly nor as com- 
pletely as in aseptic wounds. Suppurative inflammation, when it attacks 
a recent wound, commences upon its surface, with which the microbes 
have been brought in contact, and the products of coagulation necrosis 
furnish a favorable soil for their growth and reproduction. In such a 
wound the process of granulation is either impeded or completely sus- 
pended until the acute symptoms have subsided, as the embryonal cells 
are converted into pus-corpuscles almost as soon as they are formed. 
From the surface of the wound the inflammation extends to the deeper 
tissues, the extension being usually along the connective tissue, fascia, 
and intermuscular septa. The parts in the immediate vicinity of the 
wound present the usual appearances of a phlegmonous inflammation. 
The pus which forms first contains dead leucocytes, while later the 
embryonal cells furnish an additional histological source for pus-corpus- 
cles. Aseptic granulating wounds are usually considered exempt from 
infection with pus-microbes. While this may be true if the whole surface 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 229 

is covered with an uninterrupted, intact layer of healthy granulations, it 
is certainly not the case if the granulations are in any way injured or 
diseased. A slight injury, as probing, may create an infection-atrium, 
through which pus-microbes enter the deeper tissues, where they may 
become the cause of a suppurative inflammation. Under unfavorable 
vascular conditions the granulations are rendered hydropic, become 
flabby and anaemic, — conditions which impair their resistance to the 
action of pus-microbes, — which then convert the kyer of embryonal 
cells most remote from the blood-supply into pus-corpuscles. The pre- 
formed toxins injure the subjacent cells, which in turn undergo the 
same fate, and thus an unhealthy, infected granulation surface becomes 
the cause of a secondary suppuration in wounds which indefinitely dela} r s 
the healing process. If in a suppurating wound the pus-microbes attack 
a vein and produce a septic thrombo-phlebitis, the essential etiological 
condition for the occurrence of the most dangerous and intractable com- 
plication, p3 T semia, has been established. 

SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 

Suppurative inflammation of a mucous membrane is alwa}^s preceded 
by a catarrhal stage, during which the amount of the physiological 
secretion is greatly increased, Proliferation of epithelial cells takes 
place with such great rapidity that the blood-supply becomes inadequate, 
when the most superficial embn T onal cells readily succumb to the specific 
action of the pus-microbes and are exfoliated as pus-corpuscles. The 
toxins become diffused in advance of the microbic invasion, and, by 
injuring the protoplasm of the cells more deeply located, prepare the 
way for the pathogenic action of the pus-microbes, and suppuration ex- 
tends more deeply. In this way ulcers form, which may remain super- 
ficial, or which may also penetrate deeply and result in perforation. The 
products of coagulation necrosis which form upon the surface of an 
inflamed mucous membrane favor the occurrence and extension of sup- 
purative lesions, as they serve as a means of fixation and propagation of 
the pus-microbes. Pus from a suppurating mucous membrane, examined 
microscopically, will show pus-corpuscles derived from leucocytes and 
embryonal, epithelial, and connective-tissue cells which have become 
detached before they are converted into pus-cells. 

I. Abscess. — An abscess is a collection of pus in the tissues. A 
collection of pus in a preformed space, such as the pleura, pericardium, 
Fallopian tubes, pelves of kidneys, etc., although resulting from a sup- 
purative inflammation of the walls lining the space, is by general custom 
and usage not called an abscess, but the presence of pus in an} T of these 
organs is indicated by the prefix pyo, to which is added the anatomical 



230 



PRINCIPLES OF SURGERY. 



locality---thus, pyo-thorax, pyo-pericardium, pyo-salpinx, pj'o-nephrosis. 
Tlie formation of an abscess is alwa3 - s preceded by a circumscribed sup- 
purative inflammation. The histological conditions which are present at 
the time pus formation commences are characterized by a richness of 
leucocytes in the connective tissue between the inflamed capillary ves- 
sels and compression of the pre-existing tissue-cells by them and the 
transuded serum. 

Suppuration commences at one or more points in the infiltrated 
area ; if the latter is the case, the different suppurating foci soon become 
confluent, forming an abscess-cavity, which increases in size in all direc- 
tions, both by the products of inflammation breaking down into pus and 
.by the mechanical pressure of the exudation and transudation upon the 




Fig. 93.— Infiltration of Connective Tissue of Cutis, with Beginning Suppuration 
in the Centre. X 500. (Billroth- Winiwarter.) 

surrounding tissues. Cheyne, in kis excellent article on suppuration, 
describes tke changes wkick precede and attend abscess formation as 
follows : " Staining sections of tissue in wkick tkese plugs are present 
with ordinary aniline dyes, it is found that, while the mass of organisms 
is internally stained, and while the nuclei in the sections have become 
well colored, there is a rin^ of tissue around the central mass of 
organisms which does not take in the stain and which presents an homo- 
geneous, translucent appearance. This ring evidently results from the 
action of the concentrated products of the micrococci, the tissues being 
brought into the condition of coagulation necrosis. After some hours a 
second ring appears at a greater distance from tke mass of organisms, 
tkis ring being composed of a dense layer of leucocytes apparently col- 
lecting where the chemical substances are more dilute and do not inter- 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 231 

fere with the life of the cells. The abscess forms by the central softening 
of the inflammatory product and increases by the successive formation 
of additional rings, which undergo in turn coagulation necrosis and sup- 
puration." The size of the abscess is determined by the nature of the 
primary cause of the inflammation, its location, and the degree of local 
and general resistance inherent in the tissues and the patient. The 
staphylococcus is found more frequently in circumscribed abscesses, 
while the streptococcus is more prone to give rise to diffuse purulent 
infiltration. A suppurating focus near a surface is not so likely to result 
in a large abscess as when it is more deeply located, as in the former 
case spontaneous evacuation in the direction offering the least resistance 
is an early occurrence, while in the latter instance such a termination is 
onty possible after the abscess has reached considerable dimensions. An 
abscess which develops in tissues debilitated b}' a contusion or some 
antecedent lesions usually reaches greater dimensions than if it occur in 
otherwise health}' tissues. In patients whose strength has been impaired 
by old age, improper or insufficient food, intemperance, mental anxiety, 
or some antecedent acute or chronic ailment it is well known that acute 
suppurative inflammation manifests a great tendency to rapid extension; 
while a vigorous, healthy body offers the most favorable conditions 
toward limitation of the suppurative inflammation. While liquefaction 
of the inflammatory product progresses from the centre toward its 
periphery, the outer zone of the inflamed area is in a condition of 
hypersemia and active tissue proliferation. The leucocytes bej'ond 
the infected area are not converted into pus-corpuscles, and with the 
products of tissue proliferation constitute an impermeable wall, beyond 
which infection cannot extend. The limit of the abscess is an aseptic 
zone of infiltration, clinically readily recognized b} T its hardness to the 
sense of touch, — the so-called abscess-wall. As many of the small vessels 
in the centre of the abscess are permanently destroyed, a collateral cir- 
culation is established in the abscess-wall and its immediate vicinity by 
the formation of new vessels, as is well shown in Fig. 94. 

According to their contents, causes, and the time which elapsed 
between the commencement of the disease which caused them and their 
formation, abscesses are divided into acute and chronic. 

(a) Acute Abscess. — The acute or hot abscess is the usual termi- 
nation of acute circumscribed suppurative inflammation. Its favorite 
location is in the connective tissue. It is always caused b}- infection 
with pus-microbes, most frequently the staphylococcus. It contains the 
characteristic yellowish, creamy pus, the pus bonum vel laudabile of the 
old authors, and shreds of necrosed connective tissue. It appears 
within a few days after the commencement of the inflammation and 



232 



PRINCIPLES OF SURGERY. 



reaches its maximum size in a short time. It is attended by the typical 
local and general symptoms which accompany acute suppurative inflam- 
mation. Acute abscess in the abdominal cavity usually develops after 
perforation of the intestine or one of its appendages ; thus, perforation 
of the gall-bladder often gives rise to circumscribed suppuration between 
the liver, stomach, and colon, and perforation of the appendix vermi- 
formis in the right iliac region, where the circumscribed collection of 
pus is called a perityphlic abscess. The loose connective tissue that 
surrounds the kidney is often the seat of an acute suppurative inflamma- 
tion, giving rise to a perinephritic abscess. The connective tissue in 
front of the bladder, the so-called cavum Betzii, when it is infected with 
pus-microbes, occasionally becomes the starting-point of an acute abscess. 




Fig. 94.— Vessels (Artificially Injected) prom Walls of an Abscess Arti- 
ficially Produced in the Tongue of a Dog. X 25. {Billroth- Winiwarter). 

In three cases of abscess in this locality, that came under my observation, 
the infection was caused by a perforation of an intestine, and in all of 
them, after incision, scraping, disinfection, and drainage, a faecal fistula 
developed subsequent!}'. Suppurative parametritis is another instance 
of acute abscess, and is usually caused b}^ infection through the uterine 
cavity or the Fallopian tubes. Perirectal abscesses following suppu- 
rative paraproctitis are frequently preceded by localized rectal lesions, 
through which infection of the connective tissue surrounding the rectum 
with pus-microbes takes place. The manner of invasian often determines 
the location and character of the abscess. Thus, in suppurative mastitis 
the abscesses which are caused by staphylococci always begin in the 
deeper part of the organ and extend toward the surface, while in in fee- 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 233 

tion with streptococci of the same part the inflammation shoots from 
some superficial abrasion and first attacks the skin, whence the process 
extends in a central direction to the deeper portions of the gland, where 
suppuration takes place (Cl^ne). This difference depends on the 
manner of invasion of the two microbes. The staphylococci enter the 
organism through the milk-ducts and act from their interior; whereas 
the streptococci, like the microbe of erysipelas, enter the tissues through 
the lymphatic vessels, and their pathogenic action is primarily observed 
at the surface. Bumm excised a portion of the wall of a commencing 
abscess of the breast, and was able to demonstrate the presence of staphy- 
lococci in the interior of the acini, and their penetration thence into the 
interacinous tissue. The phlegmonous inflammation of the breast 
caused b}^ streptococci takes place along the course of the lymphatics, 
and primarity involves the interacinous connective tissue. 

Diagnosis. — The recognition of an acute abscess is usually not 
attended by any great difficulties. The history of an attack of acute 
suppurative inflammation is the first thing to be taken into considera- 
tion. Fever is usually present, but if the abscess has been caused by 
the micrococcus pyogenes tenuis it may be slight or entirely absent. 
The location of the abscess has also considerable influence on the 
temperature. There is no doubt that the same kind and number of pus- 
microbes in some tissues produce either a larger quantity of phlogistic 
substances, or that these in some localities and certain tissues find a 
more ready entrance into the circulation. Pain is always present, but is 
variable in intensity according to the location of the abscess and the 
nature of its surroundings. It is severe if the abscess involve parts 
freely supplied with sensitive nerves, and where the inflammatoiy product 
gives rise to an unusual degree of tension. Thus, a small abscess under- 
neath the deep fascia of a finger will cause more suffering than a large 
abscess in loose connective tissue. A beginning abscess can usually be 
accurately located by ascertaining the exact point of tenderness on 
making pressure with the tip of a finger. If the abscess is sufficiently 
near the surface, fluctuation can be felt as soon as central liquefaction 
has occurred. Redness of the skin and diffuse oedema over and around 
the abscess are important symptoms, denoting the presence of pus. 
Remembering all the symptoms which point to the existence of abscess, 
in doubtful cases an absolute diagnosis should not be made by rel} T ing 
upon any one or all of them, as by doing so serious blunders have been 
and will be made in treatment. Aneurisms have been incised under the 
belief that they were abscesses, and the less serious mistake has been 
made of treating an abscess for an aneurism. The late Professor Gunn, 
who was well known as a careful and clever diagnostician, incised a large 



234 PRINCIPLES OF SURGERY. 

angioma in the occipital region, having mistaken it for an abscess. An 
inflammatory swelling occurring in localities where aneurisms are liable 
to be met with — that is, in the course of large blood-vessels — should be 
examined with the utmost care before an incision is made. The most 
difficult cases for diagnosis are the few instances where a suppurative 
inflammation occurs around an aneurismal sac. Fortunately, we are in 
possession of a very simple diagnostic expedient, which, if resorted to, 
as it should be, in all doubtful cases, will enable the surgeon, with 
infallible certainty, to ascertain the presence or absence of pus in an 
inflammatory swelling, and this is the use of the exploring syringe. An 
ordinary hypodermic needle with a long point will answer the purpose, 
although every surgeon should be supplied with an exploring S3a*inge 
made for this special purpose. The needle must be rendered thoroughly 
aseptic by heating it in the flame of an alcohol-lamp. The surface where 
the puncture is to be made is thoroughly disinfected, and the needle is 
inserted somewhat obliquely toward the centre of the swelling and 
pushed boldly forward in this direction until resistance ceases, which 
is an indication that it has reached a cavity; the piston of the syringe is 
now slowty withdrawn and the fluid aspirated is examined ; if it is pus 
the diagnosis is made and the needle is withdrawn. If no pus is found 
the exploration is carried deeper, and, if necessary, in different directions 
without removing the needle, by making aspiration at different points so 
as to explore fully the tracks made by the needle. If no positive 
diagnosis can be made it ma}^ become necessary to repeat this method 
of examination in a few days. A. rapids-growing sarcoma may simulate 
a suppurative inflammation so closely that great care is necessary to 
distinguish between these affections before any operative procedure is 
advised or undertaken. In exploring for pus in deep-seated abscesses 
in the abdomen or pelvis, care should be exercised to insert the needle 
in such a direction, whenever this is possible, as not to penetrate the 
free peritoneal cavitj 7 ; whenever this cannot be done it should be intro- 
duced in such a manner that, after its removal, the puncture is sufficiently 
oblique to prevent the escape of pus. In such cases it is always advisa- 
ble to combine aspiration with exploration. If the tension in the abscess 
is diminished by removing a portion of its contents extravasation is less 
likely to occur. 

Treatment. — A correct diagnosis made, the old rule ubi pus ibi 
evacuo is as applicable and wise to the treatment of an acute abscess at 
the present time as it was centuries ago. Nothing is gained b} T expect- 
ant treatment. The popular belief that an abscess should be drawn 
near the surface by the use of filthy poultices before it should be opened 
is fallacious both in theory and practice. An abscess is ready to be 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 235 

opened as soon as an adequate quantity of pus has formed to constitute 
an abscess sufficient in size to be recognized by the surgeon as such. 
Students have generally been taught that an abscess should be evacuated 
by a free incision. This advice dates back to the time when antiseptics 
were not known and tubular drainage had never been heard of. The 
laying open of an acute abscess by an extensive incision is no longer 
necessary. The indications in the surgical treatment of an acute abscess 
are to open it in such a manner as to secure perfect evacuation and to 
resort to such means as will prevent re-accumulation of pus. These indica- 
tions can be fulfilled much better by making multiple small incisions and 
establishing free drainage by the insertion of tubular drains than by 
making a single long incision ; at the same time, such treatment will 
leave the parts in better condition for rapid healing than by the old- 
fashioned incisions. The incisions need never be more than an inch in 
length, through which a rubber drainage-tube the size of the little 
finger can be readily introduced. Abscesses up to the size of an orange 
do not require more than one incision. Abscesses larger than this 
should be treated by thorough drainage wherever this is possible. In 
deep-seated abscesses the first incision is made at a point where fluctua- 
tion is most distinct, or in the direction of the track of the needle of 
the exploring syringe, if the pus has been located by the use of this 
instrument. Instead of incising the abscess with one stroke of the 
knife I always incise the skin and fascia to the extent of an inch, and 
then with a pair of sharp-pointed haemostatic forceps I tunnel the inter- 
vening tissues. As soon as the point of the instrument has reached the 
abscess-cavity, pus will escape along the side of the instrument ; the 
handles of the forceps are now unlocked and the blades separated suf- 
ficiently so that upon the withdrawal of the instrument the opening is 
enlarged sufficiently to introduce a drainage-tube of requisite diameter. 
If counter-openings are to be made, the same forceps is carried across 
the abscess-cavity and pushed from within outward at a point where 
drainage is most required, the skin over the point is cut with a knife, the 
opening dilated, and a drainage-tube drawn through. The surface over 
the abscess and a considerable distance beyond it should be shaved and 
disinfected before the abscess is opened. After incision and drainage 
the abscess-cavity is washed out with a weak antiseptic solution until 
the fluid returns clear, when an absorbent antiseptic dressing is applied. 
After twenty-four or forty-eight hours the dressing is removed, the drain 
shortened, or, if through drainage has been made, the drain is cut 
through in the middle and each opening is drained separately. If sup- 
puration has not ceased, the cavity is again irrigated. It is seldom that 
an abscess-cavity heals without further suppuration after it has been 



236 PRINCIPLES OF SURGERY. 

incised and drained, even under the strictest antiseptic precautions. The 
inner lining of the walls of the abscess remains infected with pus- 
microbes, and a limited suppuration, even in the most favorable cases, 
continues, at least until after the second dressing. The dressings should 
be so applied as to make equable compression, for the purpose of keep- 
ing the surfaces of the abscess-cavity in accurate apposition. The 
drainage-tubes are removed as soon as suppuration has ceased, when 
healing of the aseptic cavity takes place by granulation, in the manner 
described in the healing of wounds. An important element in the treat- 
ment of abscesses is to secure absolute rest for the part affected. Pa- 
tients suffering from large abscesses should be kept in bed, and in the 
treatment of similar affections of one of the extremities rest is secured 
by the application of a well-padded splint, which will not only prove an 
efficient means of mitigating pain, but will keep the parts in a condition 
most conducive to rapid healing. 

(b) Chronic Abscess. — Chronic, congestive, cold, or, as it is some- 
times called, migrating abscess can most always be traced to some 
specific chronic inflammation, most frequently of a tubercular nature. 
What has been called a chronic abscess is very often no abscess at all. 
In tubercular processes the product of tissue proliferation undergoes 
coagulation necrosis and disintegrates into a granular mass, which, when 
mixed with a sufficient quantity of serum, forms an emulsion that 
macroscopically resembles pus, but under the microscope shows none of 
the histological elements which are found in true pus. An abscess can 
only be called such if it contain pus. A true chronic abscess can origi- 
nate in a tubercular actinomycotic or syphilitic lesion when the granula- 
tion tissue is secondarily infected by the localization of pus-microbes, 
which convert the embryonal cells into pus-corpuscles. Occasionally 
secondary infection with pus-microbes of such a granulating focus is 
followed by an acute phlegmonous inflammation, which extends rapidly 
to the surrounding tissues ; but usually the suppurating process pro- 
gresses slowly, and is not attended by any of the S3 r mptoms of acute 
inflammation. What has been described as a cold abscess is a cavity con- 
taining the debris of the product of a tubercular inflammation, and is 
usually in communication with the primary tubercular lesion. Such 
abscesses frequently appear at a distance from the primary seat\)f the 
disease. Thus, tuberculosis of the vertebrae gives rise to a lumbar 
abscess if the swelling appear in the lumbar region. It is called a 
psoas abscess if the tubercular product gravitate along the course of the 
psoas muscle and appear as an abscess underneath Poupart's ligament. 
Abscesses originating in the hip-joint often make their first appearance 
over the outer or inner aspect of the thigh, some distance below the 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 237 

joint. Abscesses originating in the shoulder-joint often wander a con- 
siderable distance away from the joint, along the course of the biceps 
or triceps muscle. 

Bacteriological examination of the contents of such abscesses will 
show conclusively whether they are true pus-containing abscesses or 
whether they are pseudo-abscesses. If cultivations are made with their 
contents, pus-microbes will grow upon proper nutrient media if it is a 
true abscess, while from the contents of a pseudo-abscess only the 
microbes of the primary infection can be cultivated. The information 
obtained by the discovery of the essential cause can be confirmed by 
inoculation experiments. Cold abscesses, as a rule, are painless, not 
tender to the touch, and give rise to little or no febrile disturbances. 

Diagnosis. — The diagnosis of a chronic abscess is based not so much 
upon the location, size, and characteristic features of the swelling as a 
careful consideration of the symptoms of the local lesion from which it 
started. Tubercular affections of the spine and hip-joints are accompa- 
nied by such well-defined sj-mptoms at the stage when abscesses form 
that the primary lesion can be located without much difficulty. A 
chronic paranephric abscess often develops in the course of a tubercular 
P3 T elonephritis. A tubercular pelvic abscess is frequently associated 
with primary tuberculosis of the Fallopian tube. A chronic abscess 
often arises around a tubercular gland and appears, in consequence of 
infection with pus-microbes, as a chronic suppurative periadenitis. In 
such cases the gland itself has undergone caseation, and is often found 
extensively separated from the surrounding tissues by the suppurative 
process. In reference to the nature of the swelling and the character of 
its contents, an exploratory puncture will furnish positive diagnostic 
information. 

Treatment. — The indications for early surgical interference in the 
treatment of chronic abscess are not so urgent as in the acute variety. 
These abscesses appear months and often j^ears after the commencement 
of the primary disease. While an acute abscess should always be opened 
under antiseptic precautions, it becomes a matter of duty and conscience 
to deal with a chronic abscess in a surgical way, only under the strictest 
and most elaborate antiseptic precautions. It is a well-known clinical 
fact that when such an abscess opens spontaneously, or is incised in a 
careless way, profuse suppuration and hectic fever follow, with only too 
often a speedy fatal result from septic infection. Additional infection 
with pus-microbes results in the destruction of the granulations which 
line the cavity, and the patient dies from septic infection. Unless the 
surroundings of the patient admit of carrying out the antiseptic treat- 
ment to its fullest and most perfect extent, a chronic abscess should not 



238 PRINCIPLES OF SURGERY. 

be evacuated by incision. A number of German surgeons have recently 
advocated the treatment of such abscesses by tapping and iodoform 
injections in preference to incision and drainage, — a method of treatment 
which has yielded brilliant results. One great difficulty in evacuating a 
tubercular abscess by aspiration is the blocking of the needle or trocar 
by shreds of necrosed tissue, which often interferes with complete evacu- 
ation. A chronic abscess should always be treated by incision if this 
treatment fail, if by such procedure the primary lesion can be made 
accessible to direct treatment. If such a course is adopted, the incision 
is made large enough so that the whole cavitj' can be thoroughly scraped 
out and all of the infected tissues removed. After thoroughly curetting 
the cavity is cleansed and disinfected, and after drying it is iodoformized. 
The wound is then sutured, drained, and treated on the same principles 
as a recent wound. The treatment of special forms of chronic abscess 
will be considered more in detail in the chapter on Surgical Tubercu- 
losis. 

2. Phlegmonous Inflammation, with Suppuration. — Phlegmonous in- 
flammation with suppuration is clinically characterized b} 7 rapid exten- 
sion of the disease without leading to a circumscribed collection of pus 
or abscess. From the pus of this form of infection the streptococcus 
can be cultivated more frequently than the staphylococcus, and in some 
cases both of these microbes are found in the same pus. The inflamma- 
tion affects the connective tissue, and extends rapidly along intermus- 
cular septa, fascia, and tendon-sheaths. This form of suppurative 
inflammation is prone to follow compound fractures, railroad and other 
crushing injuries, and all injuries attended b} 7 extensive contusion of 
connective tissue. The first symptoms usually appear within four days 
after the injury. The general symptoms are ushered in by n chill, fol- 
lowed by high temperature and rapid pulse. The first local symptoms 
are a copious, sanious discharge from the wound and a rapidly-spreading 
oedema. The tissues are infiltrated with the same kind of fluid, and if 
life is prolonged sufficiently long a diffuse suppuration is inevitable. 
The symptoms of sepsis in this affection predominate because the pus- 
microbes have invaded an extensive area of tissue, and are reproduced 
with great rapidity and gain entrance into the general circulation at an 
early stage ; at the same time the necrosed tissues, saturated with the 
bloody serum, furnish a good soil for the growth of putrefactive bacteria. 
In most of these cases the septic cellulitis is accompanied by lymphangitis, 
the parts presenting an erysipelatous appearance. 

Treatment. — Phlegmonous inflammation of the type just described 
calls for early and energetic treatment before suppuration has appeared. 
The pus-microbes are present in such quantities that the connective 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 239 

tissue, partially devitalized by an injury, becomes necrosed from the 
local toxic action of the ptomaines of the pus-microbes. To render such 
wounds aseptic is one of the most difficult tasks in surgery. Small 
incisions and drainage will not accomplish the desired object. The 
infected tissues must be freely exposed by as many incisions as may be 
required. The secondary disinfection in such a case must be regarded 
in the light of a capital operation. The patient should be placed under 
the influence of an anaesthetic, the limb shaved and disinfected, and by 
large incisions the infected tissues must be rendered accessible to direct 
means of disinfection. Before undertaking the operation the limb 
should be rendered bloodless by applying Esmarch's constrictor. 

In compound fractures the tissues immediately over the fragments 
should be incised sufficiently so that the fractured ends can be turned 
out. The infected medullary tissue should be scooped out with a sharp 
spoon, and all clots and necrosed tissue removed ; the parts are then 
thoroughly irrigated with corrosive sublimate (1 to 1000), or carbolic 
acid (1 to 20), after which the whole surface is dried and brushed over 
with a 10-per-cent. solution of chloride of zinc. Pockets and sinuses 
which cannot be reached with the sharp spoon can be rendered aseptic 
by pouring in peroxide of hydrogen, which, in such cases, is a remedy 
of great value. The bones are then placed in proper position, a number 
of counter-openings made, and a sufficient number of tubular drains in- 
troduced ; after which a copious antiseptic dressing is applied and the 
limb property immobilized, great care being taken to prevent decubitus 
or gangrene from pressure by protecting the parts exposed to pressure 
with antiseptic cotton. 

During the subsequent treatment such a limb should be slightly 
elevated and suspended. If after such treatment the temperature is not 
lowered within six hours and the remaining symptoms are not improved, 
it is evident that the secondary disinfection has not succeeded in obtain- 
ing an aseptic condition of the wound. If amputation does not appear 
to be indicated at this time, another effort should be made to secure 
asepticity by resorting to permanent irrigation. The antiseptic dressing 
is removed and not re-applied. The parts are covered with a compress 
wrung out of a J-per-cent. solution of acetate of aluminum, and constant 
irrigation made with the same solution. The simplest arrangement for 
constant irrigation is a reservoir holding the warm solution suspended 
over the patient's bed, and connected with the principal drainage-tube 
by means of a rubber tubing and a glass tip. In large, open, suppurating 
wounds and compound fractures the apparatus shown in Fig. 95 can be 
used to advantage. By siphon action the fluid is conducted from the vessel 
to every part of the wound. The amount of fluid flowing through the tube 



240 



PRINCIPLES OF SURGERY. 



can be regulated by compressing the tube to the desired extent with a 
clothes-pin. The limb being suspended, the fluid is conducted away 
from it into a vessel by means of a sheet of rubber cloth, mackintosh, or 
gutta-percha. 

Constant irrigation with a harmless, non-toxic, yet efficient germi- 
cidal solution in these cases is of tbe greatest value, as the wound-secre- 
tion is constantly washed away, and, as no accumulation can take place, the 
danger of sepsis from products of putrefaction is greatly diminished ; at 
the same time the tissues are kept constantly saturated with the solution, 
which at least will exert a potent inhibitory influence upon the action and 




Fig. 95.— Irrigating Apparatus. 



multiplication of pus-microbes in the living tissues. Should a faithful 
attempt at obtaining an aseptic condition by this method of treatment 
prove inefficient after a fair trial, the question of sacrificing a limb, to 
save, if possible, a life, will present itself. 

Helferich has abandoned small incisions and drainage-tubes in the 
treatment of extensive phlegmonous inflammation and has substituted 
for them laying open of the entire field of inflammation by an incision 
from one end to the other, and after thorough disinfection packs the 
cavity with aseptic gauze saturated with a solution of boric and salicylic 
acid or acetate of aluminum. 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 241 

In the absence of recognizable secondary foci in distant organs, the 
surgeon will not be able to ascertain whether a fatal form of general 
infection exists in a special case, and it is therefore always justifiable to 
resort to a mutilating operation as a last resort, provided the patient's 
strength warrants such a procedure. As in cases of progressive gan- 
grene, so in cases of progressive phlegmonous inflammation, it is ex- 
ceedingly difficult to decide upon the exact location where the amputa- 
tion should be made, as a distinct line of demarcation between healthy 
and infected tissues is never present. The only rule to go by in the 
selection of the site of amputation is to secure healthy skin-flaps and to 
make the circular section of the muscular tissue above the tissues pre- 
senting macroscopical evidences of infection. The condition of the 
deep connective tissue furnishes important information concerning this 
question. The infection is sure to extend as far as any undermining or 
sloughing of connective tissue has taken place ; hence, amputation should 
be done above these limits. The general treatment of phlegmonous 
inflammation is considered upon the same principles as the treatment of 
sepsis from other causes. 

3. Progressive Purulent Infiltration. — This is the purulent oedema of 
Pirogoff. It is a more advanced stage of what has just been described 
as progressive phlegmonous inflammation with suppuration. Purulent 
infiltration follows upon the heels of phlegmonous inflammation, and is, 
consequently, clinically also noted for its progressive character. The 
infiltration is often very extensive, involving, in many cases, an entire 
extremity. It is always attended by extensive connective-tissue necrosis. 
The pus burrows deeply among the muscles and detaches the skin over 
a large surface. The external appearances seldom indicate the extent of 
the disease. If the skin is incised freely the parts beneath, the muscles, 
vessels, and nerves, appear as plainly as in a dissection made to show the 
relation of these parts. Purulent infiltration following progressive 
phlegmonous inflammation has often been mistaken for e^sipelas, and 
has been called phlegmonous erysipelas. If purulent infiltration com- 
plicate erysipelas, it occurs in consequence of secondary infection with 
pus-microbes, and not as a result of the action of the streptococcus of 
erysipelas. The gravity of this disease depends largely upon the extent 
of the tissues involved. If it affect an entire limb the danger to life is 
great. Death may occur from pyaemia or exhaustion. 

Treatment. — The surgical treatment is the same as in abscess, only 
that the incisions should be made longer, two or three inches in length, 
in order to enable the operator to remove the necrosed connective tissue 
and to insert large tubular drains. After the first incision is made a 
long, curved, Pean forceps is introduced, the cavity explored, and 

16 



242 PRINCIPLES OF SURGERY. 

counter-openings made upon the point of the instrument in places where 
drainage will be most effective. The cavity must be drained at different 
points from one end to the other. If the forceps is not long enough to 
reach both extremities it is removed and inserted again into the second 
opening, and so on until the cavity is thoroughly drained. It is advisable 
to bring each drainage-tube out of two openings and secure each end with 
a safety-pin. In cases of purulent infiltration of an entire lower ex- 
tremity I have often made as many as twelve incisions and inserted 
half as many drainage-tubes. After the cavity has been thoroughly 
drained, it is washed out with one of the milder antiseptic solutions. An 
excellent solution for this purpose is iodinized water. This can be readily 
prepared by adding tincture of iodine to sterilized water until the solu- 
tion has the color of sherry-wine. A solution of this strength is a valu- 
able antiseptic, and can be used repeatedly and in large quantities without 
fear of causing intoxication. I have never succeeded in rendering such 
a large suppurative cavity aseptic with one irrigation, and have conse- 
quently abandoned the occlusive antiseptic dressings in these cases. It 
is much better to apply a compress wrung out of warm salicylated water 
or a 1-per-cent. solution of acetate of aluminum, which can be removed 
and re-applied every time the cavity is irrigated, which at first should 
be done every four to six hours. The warmth and moisture of the com- 
press can be maintained by covering it with gutta-percha tissue or mack- 
intosh cloth. As burrowing of pus often does not stop even after efficient 
drainage has been established, the case should be watched with great 
care, and any attempt at burrowing should be promptly met by free 
incision and additional provision for drainage. It is always advisable 
to support the limb in proper position upon some kind of a suspension 
splint, both for the purpose of securing rest and to prevent contractures. 
As soon as suppuration has nearly ceased the drains are shortened and 
irrigations made less frequently. It is a consolation to know that such 
patients, especially if they are not advanced in years, and are free from 
any other disease, often rally and make an excellent recovery after their 
strength has been reduced to a dangerous extent and their bodies re- 
duced to a skeleton by the prolonged suppuration and septic fever. If 
suppuration is not controlled by drainage and antiseptic irrigation, and 
especially if the temperature and pulse indicate a continuance of absorp- 
tion of septic material, continuous antiseptic irrigation should be insti- 
tuted, and, if this fail, amputation may become an unavoidable necessity. 
If amputation is decided upon the deep incision must be made beyond 
the limits of the suppurating area. If the suppuration has extended as 
far as the hip-joint it may become necessary to utilize for flaps the skin 
which has been undermined, in order to secure a covering for the stump. 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 243 

If such a procedure become necessar}' the internal surface of the skin- 
flaps must be rendered aseptic by using the sharp spoon and scissors in 
freeing it from infected tissue. During the whole course of the disease, 
which gives rise to purulent infiltration, the patient's strength must be 
supported by stimulants and tonics and a concentrated nutritious diet. 

4. Suppurative Tendo-vaginitis. — Another form of rapidly-spreading 
inflammation is suppurative tendo-vaginitis. As the name implies, it 
is an acute inflammation of tendon-sheaths terminating in suppuration. 
It occurs most frequently in the tendon- sheaths of the fingers, hand, and 
forearm. It develops usually from an infected wound of the finger or 
hand, or as a complication in the different forms of paronychia. The 
inflammation travels along the course of the tendon, starting, perhaps, 
from one of the tendons of a finger, extends to the palm of the hand 
underneath the annular ligament to the flexor muscles of the forearm, 
where it often produces a phlegmonous inflammation which, in the course 
of time, may involve the whole forearm. The tendons are often de- 
stroyed, and can be pulled out after a few weeks, — an occurrence which 
is always followed by permanent functional impairment of the affected 
finger or of the whole hand. Not infrequently suppurative inflammation 
of a tendon-sheath extends to one or more joints over which the tendon 
passes, causing a complication, which often necessitates amputation. 
This affection is always attended by severe pain, and, if extensive, by 
grave constitutional disturbances. The extent of the disease can be 
ascertained, approximately, at least, by the extent of the external swell- 
ing, and especially by the tenderness along the course of the tendon. 
Frequently the inflammation attacks adjacent tendon-sheaths and the pus 
undermines the entire palmar fascia. 

Treatment. — The surgical treatment of suppurative tendo-vaginitis 
must be thorough if it shall be efficient. If it follow in the course of a 
wound, the tendon in the wound is exposed ; if it develop during an 
attack of paronychia, it is laid bare by a free incison. Along the course 
of the tendon a curved forceps is passed to the upper limits of the in- 
fected part of the tendon-sheath, another incision is made down upon the 
point of the instrument, and a drainage-tube is drawn through. If the 
end of the suppurating cavity has not been reached the forceps is again in- 
troduced through the second incision down to the tendon, a third incision 
made higher up, and another drainage-tube drawn through. These ma- 
noeuvres are repeated until the upper extremity of the suppurating cavity 
is reached. Taking it for granted that the suppurative tendo-vaginitis 
commenced in the distal portion of the middle finger, and has reached 
as far as the muscles of the forearm, the first drain should reach as far .is 
the metacarpo-phalangeal joint, the second from here to the middle of the 



244 PRINCIPLES OF SURGERY. 

palm of the hand, the third from here to above the annular ligament, and 
the fourth as far as the middle of the forearm, and if suppuration has ex- 
tended farther it will become necessary to extend drainage higher up by 
another drain. If the whole palmar fascia is undermined, a drain should 
be placed transversely across the hand. If the suppuration has extended 
to adjacent tendon-sheaths, more extensive provision for drainage will be 
required. The subsequent treatment is the same as in cases of purulent 
infiltration. Necrosed tendons separate very slowly, but it is better to 
leave their elimination to the granulating process, as it is difficult to 
decide how much of the tendon should be removed, and its operative re- 
moval would often require large incisions, which would heal at best only 
slowly, and the large cicatrix would only add to the functional impair- 
ment of the member. From time to time traction can be made upon the 
tendon where it is exposed, so as to remove it as soon as it has become 
partially or completely detached. Passive motion and massage must be 
instituted as soon as the abscess has healed, so as to restore the func- 
tion of the limb as far as compatible with the existing condition, as not 
only the affected finger but the whole hand often will be found to have 
suffered seriously from the attack. If one of the principal tendons of a 
linger has sloughed and motion cannot be restored, it is advisable to im- 
mobilize the finger in a slightly-flexed position, as a curved finger is more 
serviceable than a straight one. Suppurative arthritis occurring in the 
course of an attack of tendo-vaginitis often necessitates amputation, 
more especially if it involve more than one joint of a finger. 

5. Paronychia. — Paronychia, felon, whitlow, are terms used to desig- 
nate an abscess of a finger. All these terms should be abolished, and 
abscesses of the finger, like of other parts, should be called in accord- 
ance with the primary disease which caused them. Hueter made a clas- 
sification upon a strictly pathological basis. The abscess may be located 
in the skin, and is then a furuncle ; it may involve the connective tissue, 
and is then the product of a phlegmonous inflammation ; it may form 
after an attack of periostitis or osteomyelitis, or, finally, it may commence 
in a joint, and is then from the beginning a suppurative arthritis. A 
suppurative tendo-vaginitis, as a primary affection of a tendon-sheath, 
has often been mistaken for an ordinary felon, and treated as such, with 
most disastrous results. Suppurative tendo-vaginitis is frequently met 
with as a secondary affection of the different pathological conditions 
which give rise to abscess of the fingers. All of the conditions which 
have been enumerated as causes of abscess of the fingers are attended by 
excruciating pain, as the anatomical conditions necessary for the produc- 
tion of this symptom — tension and abundant supply of sensitive nerves — 
are pre-eminent in inflammatory affections of the fingers. The pain is of 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 245 

a throbbing character, and is always aggravated by placing the hand in a 
dependent position, as the venous congestion produced by this position 
increases the swelling, and consequently the tension, in the inflamed part. 

Treatment. — Volumes have been written on the abortive treatment 
of paronychia, — the surest indication that none of the various means sug- 
gested have proved successful. Abscesses of the fingers, as in any other 
part of the body, result only from infection with pus-microbes ; hence, 
any measure which falls short of effecting complete sterilization at the 
primary focus of infection must necessarily fail in accomplishing the 
desired object. The only rational treatment consists in the employment 
of such measures as will limit the extension of the suppuration. One of 
the most important elements in the early treatment of a felon is to 
diminish the blood-supply to the inflamed part by placing the limb in an 
elevated position, and by the continued application of cold. The use of 
ice in such a superficial inflammation will not only tend to diminish the 
congestion, but at the same time it has a positive influence in retarding 
the reproduction in the tissues of the primary cause, — the pus-microbes. 
Poultices should never be employed. If position and the use of cold do 
not afford relief, moist, hot, antiseptic compresses should be applied. As 
soon as pus has formed it must be liberated by incision. The centre of 
the inflammatory focus is accurately located by marking out by pressure 
the area of tenderness, and the incision is made at this point parallel to 
the long axis of the finger. Scrupulous care must be exercised in ren- 
dering the whole surface of the finger aseptic before the incision is made. 
It is not good practice to make the incision invariably down to the bone, 
as the inflammation may not extend to this depth. The incision is only 
carried down to, but not beyond, the suppurating focus; hence, it is 
made down to the bone only if the abscess has originated in a joint or 
has followed an osteomyelitis or periostitis of a phalanx. As the wound 
gapes freely, drainage is not required. The abscess is washed out with an 
antiseptic solution and the finger dressed antiseptically. Suppurative 
arthritis is treated by through drainage. In osteomyelitis followed by 
necrosis the sequestrum is allowed to separate and is then extracted, 
which can usually be done after three or four weeks. Excellent results 
are obtained after the loss of a complete phalanx, as the bone is often 
reproduced almost to perfection by the periosteal sheath. Amputation 
only becomes necessary in cases of osteomyelitis affecting more than one 
phalanx, complicated by suppurative arthritis of the adjacent joints. 

6. Suppurative Folliculitis. — Suppurative folliculitis is a very common 
affection and represents an abscess on the smallest scale. The outlet of 
the hair-follicle is narrowed by the acute inflammation and retention of 
the secretions, and suppurative inflammation is the result of this stenosis. 



246 PRINCIPLES OF SURGERY. 

The hair occupies the centre of the minute abscess-cavity. The affection 
appears clinically usually as a multiple affection and is well represented 
by sycosis. 

7. Furuncle. — A furuncle is a small abscess of the skin. The centre 
of a furuncle is always occupied by a plug of necrosed connective tissue 
vulgarly called a core. Longard has made a careful microscopico- 
bacteriological examination of 9 cases of furunculosis in young children. 
In 4 of these cases he found the staphylococcus pyogenes albus alone, in 
5 cases in combination with the staphylococcus pyogenes aureus. The 
identity of these microbes with those described by Rosenbach was 
demonstrated by cultivation and experiments on rabbits. The microbes 
were not found in the faecal discharges of the patients, but were discov- 
ered, in small numbers, in the diapers of healthy, unclean children, as 
well as in the diapers of those suffering from suppurative folliculitis. 
He believes that the pus-microbes are the direct and sole cause of the 
affection, and that infection takes place through the sweat-glands, as the 
microbes were found in abundance upon the inner surface of the mem- 
brana propria of these glands. As soon as the microbes reach the 
subcutaneous connective tissue they produce suppurative inflammation. 
Experiments on dogs and rabbits, by cutaneous inoculations with pus- 
microbes cultivated from the furuncles, produced a slight swelling and 
redness, and, in some instances, the formation of small pustules. The 
result of these inoculations was always the same, whether the cultures 
were made from the pus of a furuncle, a suppurating wound that healed 
without fever, or from a pysemic patient. The inoculation experiments 
of Garre, Bockhardt, and Bumm, upon themselves, have been previously 
referred to, and they prove that many of the circumscribed suppurative 
affections of the skin (among them furuncle) are caused by the direct 
inoculation with pus-microbes, which enter the connective tissue either 
through a slight abrasion or through the glands of the skin. Furuncles 
often appear multiple, either in the same region or widely separated from 
each other over different parts of the body. In such cases the successive 
appearance of furuncles would tend to prove the reproduction and diffu- 
sion of the primary cause, the pus-microbes, over the surface of the body. 

Treatment. — The prophylactic treatment consists in securing for the 
skin a healthy condition. By the free use of hot water and potash-soap 
the openings of the glands of the skin are cleared of accumulation of 
pus-microbes and of materials which might serve as culture substances. 
In patients suffering from furuncle, the slightest abrasions should be 
treated with care, in order to guard against infection. If the general 
health has been impaired, dietetic and medical treatment should be insti- 
tuted to correct the faulty nutrition. We have no special internal 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 247 

remedies to correct a supposed suppurative diathesis which does not 
exist. Sulphide of calcium, which has been recommended in such strong 
terms, has no influence either in the prevention or cure of furuncles. 
With the first appearance of a furuncle, the skin over and considerably 
beyond it should be disinfected, and a compress saturated with a weak 
antiseptic solution applied. As soon as pus appears it is evacuated 
through a small incision, and if the necrosed tissue in its centre has 
become detached it is extracted. The interior of the small abscess is 
then disinfected and a small antiseptic dressing applied. A furuncle is 
an insignificant lesion, but its proper treatment should not be neglected, 
as numerous cases have been reported where thrombo-phlebitis, pyaemia, 
and acute suppurative osteomyelitis could be traced to infection from a 
furuncle. 

8. Carbuncle. — A great deal of confusion has been created in the 
minds of students in reference to what is really meant by a carbuncle. 
This confusion has been brought about by the teachings of some of our 
text-books, both old and recent, which assert that carbuncle is always 
caused by infection with the bacillus of anthrax, while others speak of a 
less malignant form of carbuncle caused by suppurative inflammation. 
Malignant carbuncle, or malignant pustule, is the anthracic form of 
carbuncle, which always starts from a single centre of infection, and is 
always attended by necrosis of the overlying skin. The ordinary 
carbuncle, which is under consideration now, is caused by infection with 
pus-microbes, and differs from a furuncle only in so far that it is made 
up of a number of foci of suppuration, which develop simultaneously or 
in rapid succession, and usually become confluent. A carbuncle of this 
kind is in reality nothing else, etiologically and pathologically, but a 
group of furuncles. A section through a carbuncle, before extensive 
liquefaction has occurred, will show a number of foci of suppuration and 
necrosis, each one of which, taken separatel}' - , would represent a furuncle. 
On account of the more extensive area of infection in carbuncle than in 
furuncle, the local symptoms are much more severe. The tissues at an 
early stage become so extensively infiltrated that the carbuncle feels as 
hard as cartilage. The pain, as a rule, is very great. In size, a carbuncle 
varies greatly ; it is sometimes not larger than a 25-cent piece, and it 
may attain a circumference fully as large as an ordinary soup-plate. 
The inflammation, which first attacks the skin and subcutaneous tissue, 
in unfavorable cases, extends to the deeper tissues and also travels in 
a peripheral direction. If the carbuncle is large, the skin covering it 
becomes gangrenous and extensive sloughing takes place. If the car- 
buncle is small, composed of onty three or four centres of suppuration, 
the skin is not destroyed, with the exception, perhaps, of a very small 



248 PRINCIPLES OF SURGERY. 

portion, corresponding to the apex of each furuncular focus. Central 
necrosis of the connective tissue in each suppurating focus invariably 
occurs, and, if the inflammation is very severe and extensive, the whole 
carbuncle becomes a necrotic mass. In mild cases the tissues between 
the suppurating foci are preserved, and, after the elimination of the 
necrosed tissue, the part presents a cribriform appearance, each depres- 
sion indicating the exact position of the former focus of infection. 
Carbuncle is met with more frequently in persons advanced in years 
and in diabetic patients, and attacks in preference such parts as are most 
exposed to infection from without, as the neck, face, and hands. The 
danger to life connected with carbuncle consists in exhaustion and septi- 
caemia, in the progressive form, while thrombo-phlebitis and pyaemia may 
occur as fatal complications, even if the disease is circumscribed and the 
local symptoms are not severe. 

Diagnosis. — The differential diagnosis consists in separating car- 
buncle from furuncle and malignant pustule, or anthracic pustule. A 
furuncle presents only one centre of suppuration, is more circumscribed, 
more superficial, and not attended by such marked infiltration as car- 
buncle. Malignant pustule is primarily not a suppurative lesion, as it 
is caused by infection with the "bacillus of anthrax, and develops from one 
point of infection and gives rise to necrosis of the skin at an early stage. 
Carbuncle starts, simultaneously or in rapid succession, from three to a 
dozen or more suppurating foci, is attended by a hard induration of the 
surrounding connective tissue, and gives rise always to multiple foci of 
necrosis of the subcutaneous connective tissue. 

Treatment. — The different methods advised, at various times, to 
abort a carbuncle have not proved more successful than the means 
suggested to check the growth of a furuncle. Very recently Beau- 
quinque has made the assertion that a carbuncle can be aborted by 
applying to the part antiseptics dissolved in alcohol. He claims to have 
succeeded in three cases by applying tincture of iodine. While we have 
no right to question the correctness of his diagnosis or the truth of his 
assertions, it is well known that the same treatment has not been 
attended by the same satisfactory results in the hands of other surgeons. 
It is difficult to conceive how the external application of the tincture 
of iodine or any other antiseptic alcoholic solution should have the 
power to destroy the pus-microbes or prevent their reproduction when 
so deeply buried in the tissues. The most potent agent to limit the 
extension of the inflammation is the continued application of ice. As 
soon as pus has formed, the different foci of suppuration should be 
exposed to direct means of disinfection by incising the carbuncle under 
strict antiseptic precautions. The old-fashioned crucial incision answers 



SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 249 

an excellent purpose. The necrosed and infected tissues are removed 
with a sharp spoon, and the surface is disinfected by irrigation with a 
solution of carbolic acid or corrosive sublimate ; after which the scraped 
surface is dried and touched with a 10-per-cent. solution of chloride of 
zinc and the part covered with an antiseptic moist compress or dressed 
on strict antiseptic principles. If the primary disinfection do not arrest 
further extension of the disease, the whole surface should be deeply 
cauterized with the knife-point of Paquelin's cautery. After cauteri- 
zation a compress saturated with a weak solution of corrosive sublimate 
is to be applied. With the cessation of suppuration granulations appear, 
when the same treatment is to be followed as in the management of 
granulating wounds. Septic thrombo-phlebitis is announced by a well- 
marked chill, followed by the usual grave symptoms which attend 
pyaemia. If the thrombosed vein can be located in such cases it should 
be removed by excision, with a faint hope that, by an early recourse to 
this expedient, a fatal form of pyaemia may possibly be prevented. 

Riedel has successfully resorted to excision of carbuncle, — a method 
of treatment which he strongly recommends. A crucial incision is made 
across the carbuncle and extending well into the healthy tissue. The 
four triangular flaps are then dissected back until healthy tissue is 
reached, and the indurated portion extirpated. The haemorrhage is con- 
trolled by compression. A loose tampon of iodoform gauze is then 
inserted in the wound, the skin having been brought back into position. 
The wound heals rapidly, and the loss of substance from the centre will 
replace itself very quickly. This operation greatly diminishes the 
danger of pyaemia and shortens the duration of the disease. 



CHAPTER X. 

Ulceration and Fistula, 
ulcer. 

An ulcer is a defect of the cutaneous or mucous surface, charac- 
terized by an absence of processes pointing to repair and an intrinsic 
tendency to peripheral extension. The process by which an ulcer is 
produced is called ulceration. An ulcer is essentially a surface lesion 
involving either the skin or any of the mucous membranes. The most 
superficial ulcer is one in which only the epithelial layer of the skin or 
mucous membrane is destroyed. A deep ulcer is one in which the cause 
which produced the ulcer has penetrated the skin or mucous membrane 
and has destroyed the subcutaneous or submucous tissues regardless of 
their anatomical structure. All ulcers are caused and are maintained by 
pathogenic microbes. They are the result of a destructive inflammation, 
and remain until the primary microbic cause has been removed or has 
been rendered harmless, when ulceration jdelds to regeneration and the 
ulcer is transformed into a granulating surface. The transition of an ulcer 
into a heajing surface takes place as soon as the embryonal cells on the 
surface of the ulcer retain their vitality and are utilized in the process 
of repair. At this, the terminal, stage of ulceration molecular destruc- 
tion and suppuration have ceased, the granulations are firm, small, and 
very vascular, and at the margins of the granulation field a delicate blue 
line indicates the beginning of epidermization. It is impossible to give 
a satisfactory description of an ulcer that will apply to all cases, as 
the appearance of the ulcer must necessarily vary according to the loca- 
tion and its size, the structure of the tissue involved, and especially the 
nature of the primary microbic cause and the character of the tissue 
changes in its immediate vicinity. Ulcers of the mucous membranes 
differ from those of the skin, owing to their being constantly bathed with 
the secretions of the affected organ; while the products of destruction of 
an ulcer of the skin frequently become inspissated and form a crust 
which may be a valuable protection to the ulcer, but which may also 
become a cause of retention of pus. An ulcer is superficial or deep 
according to the depth to which the microbic cause has penetrated and 
destroyed the tissues. The size of the ulcer is also a sure indication 

(250) 



ULCER. 251 

of the extent of infection of the affected surface. Resistance to ulcer- 
ation is not shared alike by all the tissues. The connective tissue readily 
yields to the microbic causes which produce ulceration, while muscles, 
bone, cartilage, and especially blood-vessels offer greater resistance. The 
microbes constantly found upon the surface and the tissues of an ulcer, 
irrespective of the primary cause, are the pus-microbes. Every ulcer 
represents an open, suppurating inflammation. In tuberculosis, gumma, 
lepra, and actinomycosis of any of the surfaces mixed infection with 
pus-microbes invariably takes place as soon as a surface defect has 
occurred, and the suppurative lesion which follows as the result of the 
mixed infection always greatly modifies and frequently overshadows the 
primary affection. The exposure of tumor-tissue to external infection 
is followed by a similar complication. Yascular disturbances, such as 
are caused by atheroma and varicose veins, are not only frequent and 
potent causes in the production of ulceration, but exert at the same time 
a very deleterious influence upon the nutrition of the tissues in the 
immediate vicinity of the ulcer. In the description of an ulcer special 
attention is given to its floor and margins. The floor of every ulcer is 
covered by what are generally called " unhealthy granulations." The 
granulations are either scanty or very abundant ; in the latter case they 
are said to be fungous. They are flabby, often pale and cedematous, 
and exhibit the destructive effect of the pus-microbes and their toxins. 
The superficial embryonal cells are transformed into pus-corpuscles as 
long as the microbic causes which produce the ulcer remain active. The 
products of coagulation necrosis are often deposited upon the surface 
of the ulcer in the form of a membrane more or less firmly attached to 
the granulations. 

Membranous deposits are found more frequently upon ulcerated 
surfaces of mucous membranes than upon ulcers of the skin. In ulcer- 
ating malignant tumors the surface of the ulcer is occupied by exposed 
tumor-tissue, the seat of infection with pus-microbes and often also with 
bacilli of putrefaction. The fcetor of the discharges from ulcers is alwa} r s 
due to the presence of putrefactive bacilli, which feed upon the dead 
tissue and live and multiply in the retained secretions. Induration of 
the base and margin of the ulcer is always suggestive of carcinoma. In 
chronic ulcers the underlying and adjacent tissues are often extensively 
infiltrated and dense, but this firmness and density is something quite 
different from the circumscribed, almost cartilaginous induration that 
characterizes the carcinomatous ulcer. In varicose ulcers the whole leg 
is often cedematous and hard. The margins of an ulcer are abrupt when 
the floor of the ulcer corresponds in size with its surface. If the mar- 
gins are undermined the floor of the ulcer is larger than its surface, 



252 PRINCIPLES OF SURGERY. 

while the reverse is the case when the margins are everted or sloping. 
In reference to kind, an ulcer is either acute or chronic. An acute ulcer 
is the result of a trauma, burn, frost-bite, followed by suppurative infec- 
tion, or of an acute suppurative inflammation which has resulted in a 
surface defect. A chronic ulcer is one of the results of a chronic inflam- 
mation like tuberculosis or syphilitic infection, or it follows localized 
impaired nutrition, the consequence of prolonged mechanical causes 
which interfere with a proper blood-supply, as is the case in ulcers 
caused by varicose veins or atheroma of arteries. In shape an ulcer 
may be round, oval, linear, or serpiginous. An ulcer is frequently called 
in accordance with the primary cause which produced it, and we speak 
of an ulcer being traumatic, syphilitic, tubercular, carcinomatous, malig- 
nant, varicose, mercurial, etc. The clinical behavior of an ulcer is often 
described by such terms as irritable ulcer, inflamed ulcer, phagedenic 
ulcer, etc., the adjectives having reference to the most prominent symp- 
tom presented by the ulcer. Among the general causes which favor 
ulcerative processes must be enumerated anaemia, acute infectious 
diseases, diseases of the cerebro-spinal centres, atheroma, varicose veins ; 
organic disease of the heart, kidne} T s, and liver ; and scurvy. 

Diagnosis. — The differentiation between the different kinds of ulcers 
is often an easy, but occasionally a very difficult, task. A correct diagnosis 
is an essential prerequisite to successful treatment. In obscure cases it 
is very important to obtain an accurate and reliable clinical history with 
special reference to the nature of the primary lesion. In ulcers com- 
plicating malignant disease it is usually not difficult to ascertain the 
existence and nature of the primary affection. Acute suppurative affec- 
tions, with or without injury, followed by surface defects which refuse 
to heal, result in ulcers the cause and nature of which can be readily 
ascertained. Ulcers following the action of caustics, burns, and frost-bite 
offer no difficulties in diagnosis. The most obscure ulcers follow de- 
fective innervation, and develop as secondary lesions in the course of 
different forms of chronic infective diseases, notably tuberculosis and 
syphilis. In ulcers due to congenital or acquired syphilis the cautious 
observer can usually find other indications of syphilis, and should make 
careful search for hyperplasia of the lymphatic glands, especially those 
of the occipital region and of the forearm, so constantly present in cases 
of constitutional syphilis. In tuberculosis of the skin and mucous mem- 
branes and the different forms of lupus the ulceration is usually preceded 
by nodules, and these can generally be found in the vicinity of the tuber- 
cular ulcer. In cases of doubt in the differential diagnosis between tuber- 
culosis, syphilis, and carcinoma, the microscope and inoculation experi- 
ments will render valuable service. The microscope can be relied upon 



ULCER. 253 

in making a positive diagnosis between carcinoma and the different forms 
of granulomata if sections are taken from the most recent and active part 
of the growth. Inoculation experiments can be relied upon in making a 
differential diagnosis between syphilis and tuberculosis, as the inoculation 
will prove negative in the former and will yield a positive result in the 
latter affection. 

Treatment. — The indications which must be met in the treatment of 
an ulcer are : 1. Removal of the primary essential cause. 2. Removal 
of indirect cause. 3. Rest. 4. Skin-grafting. The first indication is 
readily complied with if the ulceration depend upon mechanical causes 
which admit of removal. An ulcer of the mucous membrane caused by a 
sharp, projecting margin of a tooth or fragment of a carious tooth will 
heal promptly upon the removal of the source of irritation. A varicose 
ulcer will heal in a short time if the patient is placed in a recumbent 
position with the limb elevated. A syphilitic ulcer, as a rule, yields 
kindly to a vigorous antisyphilitic treatment. As ulceration is alwa}^s 
caused by infection with pus-microbes, a vigorous antiseptic treatment 
of the ulcerated surface is best calculated to transform an ulcer into a 
healthy, granulating surface. Nothing has yielded better results in my 
hands, in accomplishing this object, than a saturated solution of acetate 
of aluminum. The vicinity of the ulcer should first be thoroughly dis- 
infected by shaving and scrubbing with warm water and potash-soap, 
after which the ulcer is covered by a thick compress of gauze wrung out 
in a warm solution of acetate of aluminum. Evaporation is prevented 
by applying over the compress gutta-percha tissue, mackintosh cloth, or 
waxed paper. If the granulations are very flabby a 10-per-cent. solution 
of chloride of zinc should be applied every three or four days. The 
compress should be kept moist and changed daily. The removal of 
indirect causes calls for medicinal agents and dietetics calculated to 
improve the general condition of the patient and removal of the primary 
affection. In tubercular ulcerations it is necessary to remove b} T excision, 
if possible, all of the tubercular tissue. In malignant ulcers the removal 
of the primary tumor fulfills this indication. In the treatment of ulcers 
of the lower extremities the first thing to be done is to confine the 
patient to his bed and place the affected limb in an elevated position. 
This part of the treatment insures rest for the affected limb and exerts 
the most direct influence in correcting the vascular disturbances. As 
soon as the ulcer has been rendered aseptic cicatrization and epidermi- 
zation should be hastened by skin-grafting. This, according to the size 
of the ulcer, can be successfully done either by Reverdin's or Thiersch's 
method. If the ulcer is aseptic preliminary scraping is not only unneces- 
sary, but painful. 



254 PRINCIPLES OF SURGERY. 

The patient must be cautioned not to use the limb too soon after a 
successful skin transplantation, as the new tissue at best is but an 
imperfect substitute for normal skin. Careful protection of the new 
skin by aseptic hygroscopic cotton and the wearing of elastic-webbing 
bandage must be continued several weeks or months after the most 
successful skin-grafting, in order to prevent recurrence of ulceration. 

FISTULA. 

A fistula is a tubular ulcer. It always communicates with the pri- 
mary lesion and marks the course of the suppurative affection which 
produced it. The existence of the fistula is the surest indication of the 
persistence of the primary cause. When it communicates with a hollow 
vise us it gives exit to part of the secretion of that organ, and is called, 
according to the communicating organ, a bronchial, pleural, gastric, 
intestinal, vesical, rectal, uterine, etc., fistula. If it lead to a deep-seated 
primary tubercular affection it is called a tubercular fistula. Tubercular 
fistula always follows the spontaneous perforation or incision of a 
tubercular abscess which fails to heal, and is always paved its entire 
length by tubercular granulations. Many fistulse in communication with 
internal organs persist in consequence of an obstruction the removal of 
which is followed by closure of the fistulous tract. The remarks on the 
etiology, diagnosis, and treatment of ulcer are applicable to fistula, with 
the exception that ulceration is a superficial process, while the presence 
of a fistula indicates the existence of a deep-seated primary lesion which 
must be reached and removed before the conditions necessary for the 
successful treatment of the fistula are established. 



CHAPTER XI. 

Suppurative Osteomyelitis. 

Suppurative inflammation of the marrow of bone is an exceed- 
ingly frequent affection in children and young adults. As a primary 
disease it is seldom met with after the skeleton has become fully de- 
veloped. The form of osteomyelitis that will be considered here is the 
so-called spontaneous variety, which occurs without direct exposure of 
the medulla to infective microorganisms from without. 

HISTORY. 

Traumatic osteomyelitis following amputation, compound fractures, 
or gunshot injuries of the bones has been recognized for a long time as 
a distinct and serious wound complication, but osteomyelitis occurring 
without such injuries was not understood until quite recently. We find 
no mention of this acute affection of bone until 1105, when J. L. Petit 
gave a description of an acute disease of the long bones which corresponds 
with what we now understand by osteomyelitis. Similar allusions have 
been made to it by Gooch, Pott, Cheselden, Hey, and Abernethy, some 
of their descriptions being sufficiently accurate to enable us to recognize 
the character of the lesion. In 1831 M. Renaud published a paper on 
u Inflammation of the Medullary Tissue of the Long Bones," in which 
he gives a report of 5 cases occurring after amputation, all having 
terminated fatally. 

Cruveilhier alludes to the remote consequence of this affection when 
he says : " The phlebitis of the bones is one of the most frequent causes 
of visceral abscesses following wounds or surgical operations in which 
the bones are involved." Roux credits Nelaton with having devised the 
term osteomyelitis in 1834, and having published a brief account of it in 
1844. In 1849 Mr. Stanley, in his excellent monograph on " Diseases 
of the Bones," gave an accurate account of the spontaneous variety 
under the title " Suppuration in Bone." In 1855 Chassaignac applied 
the term osteomyelitis for the first time to the spontaneous variety, re- 
porting at the same time 4 cases that came under his own observation. 
Among the surgeons who have increased our knowledge of the traumatic 
variety, the names of Yallette, M. Roux, Jules Roux, Larrey, PirogorT, 
Lidell, and Allen deserve well-merited mention. In 1865 W. Roser gave 

(255) 



256 PRINCIPLES OF SURGERY. 

a complete resume, in thirty propositions, of what was then known con- 
cerning the spontaneous variety. On account of the multiplicity of the 
bone affection, and the frequency with which the joints are involved, he 
called the disease " pseudo-rheumatism." The infectious origin of trau- 
matic osteomyelitis bas been recognized for a long time, but the sponta- 
neous form was believed to be purely inflammatory until Luecke first 
called attention to its infectious character. Demme, Volkmann, Schede, 
and Hueter have added valuable contributions to the modern literature of 
non-traumatic acute suppurative osteomyelitis. Pasteur detected in osteo- 
myelitic pus a microbe which he claimed was identical with the microbe 
found in furuncles ; hence he spoke of osteonryelitis as " furuncle of bone." 
The bacteriological and experimental researches of Kocher, Rosenbach, 
Passet, Krause, and Kraske have established the fact that non-traumatic 
osteomyelitis, like the traumatic form, is a suppurative inflammation of 
the medullary tissue, caused invariably by infection with pus-microbes. 
Primary suppuration in bone begins in the medullary tissue ; hence it is 
not correct to speak of a suppurative ostitis, as is so frequently done 
among English and American authors. Primary suppurative periostitis 
is an exceedingly rare affection; consequently, osteomyelitis must be 
considered as the most frequent of all inflammatory diseases of bone. 

BACTERIOLOGICAL AND EXPERIMENTAL INVESTIGATIONS. 

Active suppurative inflammation in bone, when it occurs independ- 
ently of an external wound, and consequently of direct infection, fur- 
nishes one of the most interesting, and, thanks to the patient and 
persevering investigations of a number of the foremost pathologists, one 
of the best-known forms of purulent infection. For years it has been 
contended, by some who made the etiology of acute osteomyelitis the 
subject of experimentation, that it is caused \)y a specific microbe not 
found in other forms of suppuration. Convincing evidence, however, 
has accumulated, which seems to leave no further doubt that the ordinary 
microbes of suppuration are the cause of this form of suppurative in- 
flammation, and that the gravity of the symptoms which attended the 
disease, as compared with other suppurative processes, is owing to the 
anatomical location and structure of the inflamed tissues, rather than to 
any difference in the microbic cause. Even before the microbic cause of 
acute osteonryelitis was understood, Kocher believed that infection, in 
some cases at least, occurred through the intestinal canal, and made some 
experiments to prove this point. He produced subcutaneous fractures 
artificially in dogs, and then fed the animals large quantities of putrid 
material, and, in some cases, succeeded in causing suppuration at tbe 
seat of injury. In his clinical experience he also observed that in many 



BACTERIOLOGICAL AND EXPERIMENTAL INVESTIGATIONS. 257 

cases of acute suppurative osteomyelitis the premonitory symptoms 
pointed to the gastro-intestinal canal as the portio invasionis. 

Rosenbach cultivated the staphylococcus from osteonryelitic pus as 
early as 1881. In one case the yellow and the white staphylococcus 
were found together, in another case the staphjdococcus alone, while in 
a third case the aureus and the streptococcus pj^ogenes were cultivated 
from the same pus. Rosenbach produced the same result in his experi- 
ments by injection of a pure culture of pus-microbes from a furuncle of 
the lip, as Struck did with cultivations from the pus of osteomyelitis, 
and with osteomyelitic pus injected into the subcutaneous connective 
tissue he produced an ordinary abscess. Recurrent attacks of osteo- 
myelitis, years after the primary disease had been apparently cured, 
Rosenbach explains by assuming that after the first attack some of the 
microbes remain in the tissues in a latent condition until, at some subse- 
quent time, local conditions are created which enable them again to dis- 
play their specific pathogenic properties. Struck obtained, from the pus 
of an acute case of osteomyelitis, upon gelatin, an orange-yellow culture; 
the identit} r of this culture with the staphylococcus pyogenes aureus was 
soon generally recognized. By injecting a pule culture into the circula- 
tion of animals whicli had been subjected, a few days before, to injury 
of bone, as contusion or fracture, he produced a suppurative inflamma- 
tion at the seat of the trauma. Krause cultivated from osteomyelitic 
pus the staphylococcus pyogenes aureus and albus, which he also found 
in the effusion of joints, when this occurred as a complication of the 
disease. Injection of a pure culture of these cocci into the peritoneal 
cavity of animals caused suppurative peritonitis. Intra-venous injections, 
with or without previous fracture, were followed most frequently by 
suppuration in joints and muscles. If a bone was fractured subcuta- 
neous^ before the injection was made, he frequently observed suppura- 
tion at the seat of fracture, and from the pus the staphylococcus could 
again be cultivated. Foci in the kidneys were always present in all of 
these experiments. Miiller succeeded in cultivating the staphylococcus 
P3 T ogenes aureus from the yellow granulations in cases of acute epiphys- 
eary osteonryelitis. Rodet succeeded in producing in animals suppura- 
tive osteomyelitis by intra-venous injections of pus-microbes, without 
inflicting an osseous injury. The suppuration, whicli was generally 
circumscribed, was usually located near the epiplrvsis ; it seldom 
involved any considerable portion of the shaft. In man} r cases separa- 
tion of the epiphysis and suppurative arthritis of the adjacent joint 
occurred. In the most acute cases, the animal died within twentj^-four 
hours, without any appreciable changes in the bones being demonstrable 
at the necropsy. Young animals proved more susceptible to inoculations. 

17 



258 PRINCIPLES OF SURGERY. 

Rodet believes that primary localization of the pus-microbes takes place 
in the medullary tissue at a point close to the epiphyseal cartilage. When 
separation of the epiphysis occurred, the pathological fracture was always 
found on the side of the diaphysis. 

Lannelongue made investigations concerning the bacteriology of 
acute osteomyelitis in 35 cases. The staphylococcus pyogenes aureus 
was found to be the immediate cause in 21, the staphylococcus pyogenes 
albus in T, the streptococcus pyogenes in 3, the pneumococcus in 2, and 
in 2 the specific microbe could not be ascertained. He claims that it is 
possible to distinguish by the symptoms between streptococcous and 
staphylococcus osteomyelitis, the fever in the former being more irreg- 
ular, the skin over the affected region much redder, with lymphangitis 
and painful adenitis. The metastases due to the streptococcus are 
articular, synovial, and serous, while those caused by the staphylococ- 
cus are visceral. The staphylococcus is more frequently met with in 
young children. The streptococcous infection is less liable to give rise to 
extensive necrosis than implication of soft parts. In osteomyelitis pro- 
duced by the pneumococcus suppurative arthritis was a constant compli- 
cation. 

Rinne, who failed in producing metastatic abscesses with pure 
cultures of pus-microbes, rendered four rabbits pysemic by injecting 
osteomyelitic pus directly into the venous circulation. He used the pus 
taken from a case of acute osteomyelitis with grave s} 7 mptoms, and 
diluted it with distilled water, and of such a mixture he injected a Pravaz 
syringefnl into one of the auricular veins of four rabbits. One died in 
twenty-four hours, with S3 r mptoms of toxaemia, and the autopsy showed 
nothing but a beginning pneumonia of left lung. The other three animals 
died seven to ten da}^s after the injection, and in all of them suppurating 
foci were found in the kidneys and the muscles of the heart. No abscess 
in muscles or suppuration in joints. The plate cultures made from the 
pus used for the experiments showed the staphylococcus pyogenes aureus 
and albus and the bacillus pj^ocyaneus. With the exception of the albus, 
all of the microbes were also cultivated from the pus of the metastatic 
abscesses. In a later communication the same author expresses the 
opinion that the indirect causes of suppurative osteomyelitis are changes 
brought about in the medullary tissue by the microbes and their 
ptomaines of general febrile diseases, such as typhus, scarlatina, diph- 
theria, etc., which prepare the soil for the action of pus-microbes, or the 
disease is produced by the direct extension from a localized suppurative 
lesion, as a furuncle, through the lymphatic vessels, or along vessel- or 
nerve- sheaths to the medullary tissue. 

Jordan found in the osteomyelitic pus, in three cases, pneumococci; 



causes. 259 

while in six other cases the disease was caused by the typhoid bacillus. 
According to the same author, the suppurative inflammation of the 
medullary tissue may also be caused, in exceptional cases, by micrococ- 
cus pyogenes tenuis, the bacterium coli commune, the bacillus pyocya- 
neus, and the micrococcus tetragenus. Lannelongue and Achard found 
in osteon^elitic pus the diplococcus pneumoniae of Fraenkel as the only 
and essential microbic cause of the inflammation. E. Fischer and Levy 
found the same microbe in the pus and blood of two children suffering 
from osteomyelitis. 

Kraske has studied, from a clinical stand-point, the manner of infec- 
tion in cases of acute osteomyelitis. In one case he could trace the 
infection distinctly to a furuncle of the lip; but, as a rule, he thinks 
that infection takes place through a wound or abrasion of the skin. In- 
fection through the intestinal canal he considers possible, but not proven ; 
more frequently it takes place through the respiratory organs, and in 
one case he could locate the infection through this route with certainty. 
He asserts that recurring attacks should not always be looked upon as 
the result of former infection, but as a consequence of a new infection of 
the old site. 

CAUSES. 

The essential exciting cause of suppurative osteomyelitis, both acute 
and chronic, is the presence of one or more varieties of pus-microbes. 
Direct extension of a suppurative lesion through the medium of lym- 
phatic vessel- or nerve- sheaths, as Rinne suggests, may be possible, but 
such a direct connection between a peripheral suppurating focus and a 
central osseous lesion of a similar nature can seldom be demonstrated. 
Infection in most instances takes place by pus-microbes which have found 
their way into the circulation from a suppurating wound or through the 
respiratory or intestinal mucous membrane, and which localize in the 
medullary tissue prepared for their reception by anatomical peculiarities 
of the capillary vessels, or by a locus minoris resistentise created by an 
injury or some antecedent pathological condition. A number of well- 
authenticated cases have been reported where a subcutaneous fracture 
became the starting-point of an attack of osteomyelitis in patients who 
suffered at the same time from a suppurating wound in a part distant 
from the fracture. In such cases it is reasonable and logical to assmne 
that pus-microbes enter the circulation and are conveyed by the blood-cur- 
rent to the seat of fracture, where they are arrested and find a favorable 
soil for their reproduction and the exercise of their pathogenic properties. 
Such cases are simply the counterpart of what has been accomplished by 
experimentation. Clinical experience and experimental research have 
shown that pus-microbes localize in preference near the epiphyseal lines of 



260 PRINCIPLES OF SURGERY. 

the long bones. During the growth of bone this region is supplied with 
new, growing, and imperfectly-developed capillary vessels, — a condition 
which cannot fail in favoring localization of floating microorganisms in 
this locality. Neumann has also called attention to a peculiarity of the 
capillary vessels in the medullary tissue, their calibre being four times 
greater than that of the arterial branches that supply them, — another im- 
portant anatomical condition which predisposes to localization of microbes 
in this tissue. Histological investigation has also shown that the small 
blood-vessels in the medullary tissue are devoid of a proper vessel-wall, 
and appear more like channels or excavations than blood-vessels, — another 
condition which must yield a potent influence in determining congestion 
in these vessels and mural implantation of infected leucocytes under the 
action of an exciting cause or causes. As Luecke has shown, and as 
Rhine again asserts, the medullary tissue is prepared for the action of 
pus-microbes by the causes which precipitate an attack of some acute 
febrile affection, as variola, typhoid fever, scarlatina, rubeola, and diph- 
theria. Keen has given a good account of all the bone-lesions following 
the continued fevers. He found 69 cases, of which 22 affected the head, 
7 the trunk, 6 the upper and 42 the lower extremities. In 37 cases the 
disease followed typhoid fever. As to the date of occurrence in 47 cases, 
10 were within two weeks, 27 from three to six weeks, and 10 some 
months after the fever. Keen's explanation was that the earlier cases 
probably resulted from thrombosis and the later from enfeebled nutri- 
tion. Trauma, if any, in these cases was always slight. Children and 
young adults who have passed through an attack of an}' one of these 
infectious diseases are strongly predisposed to an attack of acute sup- 
purative osteon^ elitis. Excluding all such influences, there is still left 
a large number of cases where osteomyelitis attacks persons otherwise 
apparently in perfect health. M} r own observations induce me to attrib- 
ute to exposure to cold an important role as an exciting cause. I do 
not wish it to be understood that exposure to cold alone could ever result 
in an attack of acute suppuration of the medullary tissue. Pus-microbes 
inhabit persons in perfect health, and the}' do not cause disease as long as 
the circulation remains normal, as localization does not take place in the 
absence of a proper soil. If, however, in such a person the circulation 
in the medullary tissue is disturbed suddenly, in consequence of a sudden 
or prolonged chilling of the surface of the body, congestion, mural im- 
plantation and localization of the floating pus-microbes occur in a locality 
which offers the least resistance in such an emergency, and a suppurative 
inflammation is established in the medullary tissue. I have repeatedly 
observed cases of osteomyelitis in boys who, after active exercise, sud- 
denly became chilled by bathing in cold water, or who, after an exciting 



SYMPTOMS. 261 

game of base-ball, stretched themselves out on the cold ground to rest. 
A disturbance of the equilibrium of the circulation from any cause is an 
important factor not only in precipitating an attack of acute osteomye- 
litis, but many other local infective processes in persons already infected 
with the essential cause. 

SYMPTOMS. 

Acute suppurative osteomyelitis is usually ushered in by a chill and 
other symptoms indicative of the commencement of an acute suppura- 
tive affection. In some cases, even daring the earliest stages, the gen- 
eral symptoms are out of all proportion to the local lesion, presenting a 
clinical picture characteristic of intense septic intoxication. I have 
observed several cases of multiple osteomyelitis where the patients 
passed into a typhoid condition, muttering delirium, dry tongue, diar- 
rhoea, and a continued form of fever, with a high temperature and rapid 
pulse, who died within a week, before the local disease had made any con- 
siderable progress. In one of these cases the patient was a young lady, 
18 years of age, in whom the disease affected both tibiae, 1 femur, both 
humeri, 1 clavicle, and several ribs from the very beginning, and the dis- 
ease proved fatal on the sixth day. In such cases the prominent general 
symptoms are those of a malignant form of progressive sepsis. It is 
possible that the ptomaines produced b}^ the pus-corpuscles in the medul- 
lary tissue may be more virulent, or that they are produced in larger 
quantities than in suppurative inflammation of other organs. Again, the 
ptomaines gain here more ready entrance into the circulation, as, at least 
in part, they are produced within the blood-vessels, and the extra-vascular 
products are forced rapidly into the circulation on account of the unyield- 
ing nature of the tissues around the primary focus of inflammation. In 
some cases of acute osteomyelitis the actual development of the disease 
is preceded by premonitory symptoms, which indicate the route through 
which infection has probably taken place. A preceding bronchial ca- 
tarrh would indicate the possibility that infection had occurred through 
the mucous membrane of the respiratory organs, while infection through 
the intestinal canal would give rise to diarrhoea as a premonitory symp- 
tom. The local symptoms will be considered separate^, as a correct 
early diagnosis can only be made by a careful study of these, individually 
and collectively. 

Pain. — Pain is one of the earliest and constant symptoms of acute 
osteomyelitis. It may be absent in multiple osteon^elitis, where the 
patient passes into a condition of stupor almost from the beginning. 
The pain is described by the patient as being excruciating, of a boring, 
tearing, or throbbing character. It is not limited to the area involved 
by the disease, but is often diffuse, extending to the adjacent joint and 



262 PRINCIPLES OF SURGERY. 

over a considerable portion of the shaft. It is caused by the great 
tension resulting from the pressure of the infiammatorj^ product in a 
tissue surrounded by an unyielding case of compact bone. Pain in- 
creases as the exudation becomes more abundant, and is diminished or 
subsides almost completely with the escape of the inflammatory product 
from the interior of the bone into the surrounding soft tissues. Sudden 
diminution of pain is almost a certain indication that perforation of the 
bone has occurred, and that the pus has escaped into the paraperiosteal 
tissues. The location of pain should be carefully inquired into, as in 
multiple osteomyelitis this symptom will locate, at an early time, the 
ji umber and location of bones affected. In multiple osteomyelitis the 
disease may appear simultaneously in several bones far apart, or the 
disease appears in one bone first, and other bones are attacked later 
successively. The appearance of pain in a new locality is generally an 
indication that another bone has become involved. 

Tenderness. — The patient is very seldom able to locate accurately 
the primary focus of the disease in an inflamed bone, as the pain is 
diffuse ; but the pain caused b} r pressure will enable the surgeon to locate 
the primary focus within the bone with accurac} r , even before an y ex- 
ternal swelling has appeared. During the first few days the area of 
tenderness will correspond to the extent of the disease in the interior of 
the bo7ie, and the centre of this area will correspond to the primary focus 
of the inflammation. Tenderness is most acute where the disease has 
approached nearest the surface of the bone, and by this means the sur- 
geon locates the site for early operation. Tenderness is caused by the 
secondary periostitis. In osteomyelitis of the long bones this symptom 
appears first near one of the epiphyses, and extends later toward the 
shaft of the bone as the periostitis ascends "or descends in that 
direction. 

Swelling. — The absence of external swelling during the first few 
days of an attack of acute osteomyelitis has often given rise to mistakes 
in diagnosis. As the primary inflammation is located in the interior of 
a bone, external swelling is absent until the inflammation has extended 
to the surrounding soft tissues. With the appearance of the secondary 
periostitis swelling occurs, which at first can be felt as a hard induration, 
soon followed by oedema and deep-seated fluctuation. The rapid local 
diffusion of the process is largely due to the unyielding nature of the 
tissues around the primary focus, and to the fact that the blood-vessels 
are directly concerned in the extension of the process by becoming the 
channels for the diffusion of the septic infection, their contents forming 
a nutrient medium for the pus-microbes. Thrombo-phlebitis is a con- 
stant and early condition in every case of acute osteomyelitis. The 



SYMPTOMS. 



263 



oedema of the soft parts is caused, in part at least, by the deep-seated 
venous obstruction. The external swelling seldom appears before the 
end of the first week, but when it once shows itself it increases very 
rapidly. The secondary suppurative periostitis results in extensive 
denudation of the bone of this membrane, a large portion of the shaft 
being surrounded by pus. As soon as the 
suppurative inflammation extends to the soft 
tissues, diffuse burrowing of pus takes place 
between the bone and the periosteum and 
among the muscles. Within a few days an 
immense abscess or a very extensive puru- 
lent infiltration develops in this manner. 

Redness. — The skin over the affected 
bone presents a pale, normal appearance until 
the pus reaches the subcutaneous tissue, 
when it presents a red or brownish-red dis- 
coloration. The superficial veins are always 
dilated and turgid, — a reliable indication of 
the existence of a deep-seated thrombo- 
phlebitis. 

Synovitis.— Inflammation of joints situ- 
ated in close proximity to osteomyelitic foci 
is the rule. Catarrhal synovitis appears 
during the first few weeks, while suppurative 
synovitis usually occurs later as a complica- 
tion of acute suppurative osteomyelitis. If 
the effusion into the joint is of a serous 
character, it occurs not as a result of infec- 
tion with pus-microbes, but in consequence 
of vascular disturbances outside the limits 
of the area of infection. The serous effusion 
appears rapidly, gives rise to pain and con- 
traction of the joint, but, as a rule, disappears 
spontaneously after the evacuation of pus. 
Suppurative synovitis follows infection of 
a joint with the same microbes that caused 

the osteomyelitis, which reached the joint either directly, through some 
pathological defect of the epiphysis, or through the lymphatics or blood- 
vessels. 

The occurrence of an attack of suppurative synovitis greatly 
aggravates the general sjmptoms, and is attended by more serious local 
disturbances than is the case if tfhe effusion is of a non-septic character. 




Fig. 96. — Osteomyelitis of 
the Tibia in a Girl, 8 
Years Old, Two Weeks 
after Beginning of the 
Disease, showing Loca- 
tion and Extent of the 
Denuded Bone. 



264 PRINCIPLES OF SURGERY. 

If any doubt exist in reference to the character of the effusion an 
exploratory puncture will furnish the necessary information. 

Epiphyseolysis. — Separation of an epiphysis from the diaphysis in 
the epiphyseal line is not an infrequent accident in cases of osteomyelitis 
of the long bones. It is a pathological fracture which occurs in conse- 
quence of necrosis, inflammatory osteoporosis, or molecular disintegra- 
tion of bone in the epiphyseal line. It is readily recognized by the 
existence of a false point of motion and the displacements which usually 
attend fractures in such a locality. Epiphyseolysis seldom occurs before 
the end of the fourth or sixth week from the beginning of the attack. 

Loss of Function. — In a limb the seat of an acute osteomyelitis all 
functions are usually completely suspended. It is as useless as though 
one of the principal bones had been fractured. The patient is unable to 
raise it, or to move the nearest joint. The limb is not only useless, but 
the patient complains of a sensation as though it would break on its 
being lifted or otherwise manipulated. 

DIAGNOSIS. 

Mr. Holmes has well said that acute suppurative osteomyelitis is 
more frequently recognized at post-mortem examinations than at the 
bedside of the sick. It has often been mistaken and treated for other 
affections, as periostitis, ostitis, inflammation of joints, rheumatism, 
typhoid fever, erysipelas, and even phlegmonous inflammation of the 
soft parts. When we remember that periostitis, ostitis, synovitis, and 
cellulitis are secondary lesions, intimately associated in the clinical 
history of every case of osteonryelitis, and, furthermore, that the fever 
attending it closely resembles typhoid fever, it is not surprising that 
mistakes in the early diagnosis of this disease are not infrequent, even 
in the practice of experienced surgeons. A careful consideration of 
every feature of the clinical picture presented by each case can only 
enable us to arrive at correct diagnostic conclusions. There is no single 
pathognomonic symptom that would infallibly lead us to a correct diag- 
nosis. The presence of fat-globules in the pus was regarded as diagnostic 
by Chassaignac and Roser. Fat-globules are often found in osteo- 
nryelitic pus, but they are not invariably present, and may also occur in 
the pus of a phlegmonous inflammation. An important element in differ- 
ential diagnosis is the abscence of external swelling for the first few days, 
regardless of the severity of other s}^mptoms ; also, its rapid effusion 
after it has once made its appearance. In periostitis and phlegmonous 
inflammation of the connective tissue swelling is one of the earliest 
symptoms. In osteomyelitis the superficial swelling is at first cedema- 
tous, extends symmetrically around the entire bone, and gradually 



DIAGNOSIS. 



265 



diminishes at a point where the morbid process in the interior of the 
bone has become arrested. In acute cases fluctuation appears about the 
end of the first or during the second week. A consecutive inflammation 
of proximal joints usually makes its appearance about from the end of 
the first to the fourth week. The time of its appearance, as well as its 
character, is determined by the causes which produce the synovitis. 
While joint affections are almost constant in osteomyelitis, they are 
seldom associated with periostitis, or plastic osteomyelitis. In osteo- 
myelitis of the tibia the phlegmonous inflammation sometimes involves 
the prepatellar bursa, in which case the swelling simulates very closely a 
complicating suppurative synovitis. The fluctuation over the knee-joint 




Fig. 97.— Osteomyelitis of Tibia Two Weeks Old, Complicated by Extension of 
Phlegmonous Inflammation to the Prepatellar Bursa. 



is, however, in such cases continuous with that of the primary osteo- 
myelitic abscess. The character of the fever which accompanies grave 
attacks of osteomyelitis sometimes obscures the local symptoms to such 
an extent as to lead the attendant to the belief that the patient is suffering 
from an attack of typhoid fever. Goltdammer has reported a typical case 
of this kind. The general symptoms simulated typhoid fever so closely 
that the patient, after an illness of ten days, was sent to the medical wards 
as a severe case of typhoid fever. The pulse ranged between 110 and 
120 ; temperature 40° to 41° C. Tympanites, dry tongue, enlargement of 
spleen, bronchitis, rapid respiration, and delirium. On close examina- 
tion, a slight swelling was found over the lower part of the right tibia, 
with tenderness on pressure, — symptoms which finally enabled the attend- 



266 PRINCIPLES OF SURGERY. 

ing physician to make a correct diagnosis. During the progress of the 
case pleuritis, parotitis duplex, and synovitis of the right shoulder-joint 
made their appearance. The patient died eight days after admission, or 
eighteen days from the beginning of the disease. The necropsy revealed 
the existence of acute osteomyelitis of the tibia and pyaemia. Many 
such cases have been recorded where the differential diagnosis between 
acute osteomyelitis and typhoid fever was difficult, if not impossible, 
until the local S3 r mptoms became more prominent. The premonitory 
symptoms in typhoid fever are more constant and prominent than in 
osteomyelitis. In the latter affection the bronchial or intestinal catarrh 
which occasionally precedes the attack constitutes the only premonitory 
symptom which has been observed, and, as a rule, the disease com- 
mences abruptly without any such warnings. Chassaignac believes that 
diarrhoea is present in almost all cases in the beginning, but it is a more 
constant symptom after septicaemia and pyaemia have made their appear- 
ance. The temperature, as a rule, shows less variation in osteonrvelitis 
than in typhoid fever. After the initial chill and the usual symptoms 
attending the subsequent fever, the first symptom that points to osteo- 
myelitis is pain. This is general^ severe, deep-seated, constant, boring, 
tearing, or throbbing in character, and referred to the primary focus of 
the disease, usually in the vicinity of the epiphyseal line. Patients old 
enough to describe their sensations complain of a feeling as if the bone 
were being broken. They object to moving or handling of the limb on 
account of fear of an aggravation of this distressing sensation. E. von 
Wahl makes the statement that fluctuation is at first circumscribed in 
phlegmonous inflammation of the connective tissue, while it is diffuse 
from the beginning in osteomyelitis. This distinction is a good one. 
The importance of searching for points of tenderness in the diagnosis 
and location of the disease has already been alluded to. The differential 
diagnosis between rheumatism, gonorrhoeal arthritis, and osteomyelitis is 
not difficult, as in the former diseases the joint affections occur as a 
primary disease, while in osteomyelitis they appear as complications. 

PROGNOSIS. 

Modern aggressive surgery has greatly diminished the mortality of 
acute osteomyelitis. Under the old, expectant, non-antiseptic treatment 
it was large. Thus, Demme lost 4 out of IT cases ; Luecke, 11 out of 
24 ; Kocher, 9 out of 26 ; and Schede, 3 out of 23 cases. Multiple osteomye- 
litis, with grave symptoms of septicaemia from the beginning, almost with- 
out exception proves fatal in less than two weeks. Death in such cases is 
caused by progressive sepsis resulting from the entrance of large quan- 
tities of pus-microbes into the circulation. After death no character- 



PROGNOSIS. 267 

istic macroscopical lesions can be found in distant organs, and micro- 
scopical examination reveals only the minute changes in the capillary 
vessels typical of acute septicaemia. If the patient escape this, the first 
source of danger to life, he is still exposed, during the existence of the 
acute symptoms, to the more remote risks incident to the presence of 
septic thrombo-phlebitis. If any of the thrombi undergo softening and 
disintegration, fragments reach the general circulation and constitute 
infected emboli, which establish in distant organs, notably the lungs and 
kidneys, independent centres of suppuration, — the so-called metastatic or 
pyaemic abscesses. The accession of this fatal complication is announced 
by recurring chills, an intermittent form of fever, and is followed within 
a short time by death from sepsis or exhaustion. Another fatal accident 
which may occur is fat-embolism. The medullary tissue is liquefied by 
the suppurative inflammation, and some of the free fat-globules may be 
forced into the circulation by the intra-osseous pressure, and death is 
preceded by rapid, shallow breathing; cyanosis; small, rapid pulse, — 
S3 T mptoms which point to the existence of an obstruction to the passage 
of the blood from the right to the left side of the heart. Extensive 
destruction of the medullary tissue is alwaj's followed by marked 
anaemia, and this condition is a prominent symptom in all cases of osteo- 
myelitis, as this disease seriously impairs the function of one of the 
important blood-producing organs. Schede has seen, in cases of acute 
osteomyelitis, the proportion of the white to the red blood-corpuscles 
increased to 1:100. The clinical thermometer is an important prognostic 
aid in this as well as in many other acute infective processes. If the 
morning and evening temperature remain continuously high, — that is to 
say, ranges from 40° to 40.5° C. during the first week, — it indicates a 
severe case. The more the general symptoms resemble a severe case of 
typhoid fever, the graver the prognosis. The occurrence of decubitus is 
always an unfavorable sign. In regard to the function of the limb after 
an attack of acute osteomyelitis, a few words are necessary. Necrosis 
of the bone, to a greater or less extent, is the rule. The extent of perios- 
teal detachment during the acute stage is no indication of the area of 
subsequent sequestration, as the greater part of the denuded bone may 
receive an adequate blood-supply from the vessels within the bone, and 
soon becomes covered with granulations, and later unites with the peri- 
osteum or the paraperi osteal tissues. Joint affections and partial or 
complete separation of one or more epiphyses are frequent complica- 
tions. A catarrhal effusion is generally removed by absorption after 
the subsidence of the acute symptoms, and the functions of the joints 
are restored completely. If the effusion is sero-purulent and the articu- 
lar cartilages remain intact, aspiration, with subsequent washing out of 



268 PRINCIPLES OF SURGERY. 

the joint with an antiseptic solution, may be sufficient to remove the 
effusion and restore the usefulness of the limb. Stiffness of the joint 
and malposition of the articular surfaces of the bones are events that 
cannot be avoided in all cases, even by the most skillful and attentive 
treatment. If the articular cartilages are destroyed by suppurative 
arthritis, the best result that can be hoped for is a useful but ankylosed 
joint. Pathological fractures through the shaft of a bone or epiphyse- 
olysis are complications which greatty tax the duties of the attending 
surgeon, but from which the patients frequently recover with a useful 
limb. 

PATHOLOGICAL ANATOMY. 

Acute osteomyelitis is essentially a phlegmonous inflammation of 
the marrow of bone. This disease attacks, preferably, the long bones, 
although the scapula, clavicle, ribs, and ilium are also frequently affected, 
especially in cases of multiple osteom3 T elitis. Of the long bones the 
femur is most frequently affected. Seventy -three per cent, of all of 
Demme's cases involved this bone. In the femur the disease manifests 
a special predilection for the lower epiphyseal region, while in the tibia 
the order of frequency is reversed. The great frequency with which 
the extremities of the shaft of the long bones are affected receives a 
plausible explanation from the activit}^ of the physiological changes 
during the growth of bone, and perhaps to a lesser extent by the greater 
frequency of traumatism in these localities. Englisch claimed that the 
extremity of the shaft and epiplrysis, toward which the nutrient artery 
is directed, is always primarily affected, on account of the greater blood- 
pressure in that locality. Clinical experience has proved the contrar}'. 
As acute osteomyelitis, without direct exposure of the marrow, is caused 
by infection with pus-microbes, which reach the tissue through the 
circulation, the inflammatory process must commence in the capillaries 
from mural implantation of microbes or leucocytes containing them. 

The cause of the inflammation is primarily endovascular, and 
reaches the medullary tissue with the leucocytes. Intense alteration of 
the capillary wall is always present in these cases, giving rise to rhexis. 
Pus from acute osteomyelitis almost always presents a reddish appear- 
once, which is owing to the presence of extra vasated blood. The inflam- 
mation extends rapidly to the larger veins, which become blocked by the 
formation of a thrombus. If pus-microbes enter the thrombosed veins 
in sufficient quantity to cause liquefaction of the coagulated blood, 
pyaemia results from transportation of fragments of such infected 
thrombi to distant organs. Extensive thrombo-phlebitis results in 
arrest of circulation in portions of the bone, or perhaps of the entire 



PATHOLOGICAL ANATOMY. 269 

shaft, which is followed by the usual consequences of such a- condition, — 
necrosis. Necrosis is undoubtedly also caused by the local toxic effect 
of the ptomaines of the pus-microbes upon the tissues and the pressure 
resulting from the presence of the inflammatory exudate in a tissue not 
capable of distention. The central medullary cavitj' is rapidly trans- 
formed into an abscess-cavity. The pus occupies either the entire 
cavity, a certain section of it, or is in the form of multiple circumscribed 
abscesses or infiltration. The infection from the central focus extends 
along the blood-vessels and soon reaches the periosteum, which becomes 
the seat of an inflammation which resembles, pathologically, the primary 
medullary lesion in eyery respect. The second aiy periostitis in eveiy 
case of acute osteomyelitis always assumes a suppurative type. Pus 
accumulates between the periosteum and bone, causing often extensive 
denudation of the bone. The periosteum at some points is destnrved 
when the pus reaches the surrounding connective tissue, which then 
becomes the seat of a phlegmonous inflammation. The periosteal defects 
are not restored subsequently, and at these points openings remain later 
in the new bone, called cloacae. After the active symptoms have sub- 
sided the suppurative periostitis gives way to a process of repair, during 
which the periosteum forms a case of new bone around the necrosed 
portion, which, in technical language, is called an involucrum. The 
abscess in the soft parts heals, and one or more fistulous communica- 
tions between the surface of the skin and the dead bone in the interior 
of the involucrum remain. The external openings are often quite distant 
from the cloacae, and in such cases it is difficult, if not impossible, to 
discover the dead bone by probing. The necrosed bone is called a 
sequestrum. If necrosis has occurred at different points several sequestra 
will be included by the involucrum. Separation of a sequestrum, like 
the elimination of necrosed soft tissues, is accomplished either by suppu- 
ration or, what is more common, by granulation. Such pieces of bone 
always show an irregular or dentated outline, which is due either to the 
original shape of the sequestrum or to the action of the granulations, 
which diminish the size of the detached bone after its separation. 
Necrosis is said to be central if the sequestrum is composed of tissue 
from the interior of the bone, complete if it represent the entire thick- 
ness of the bone, and cortical if it is composed of the external compact 
layer only. In complete necrosis a pathological fracture necessarily 
takes place if separation occur before a firm involucrum has formed. 
In such cases restoration of the continuity of the bone is effected by the 
new bone. In central necrosis the dead bone is always encased in an 
involucrum. In cortical necrosis spontaneous elimination of the seques- 
trum frequently occurs if the bone separate before an involucrum forms 



270 



PRINCIPLES OF SURGERY. 



around it, or, if an involucrum does not form, on account of destruction 
of a corresponding portion of the periosteum. 

The medullary canal in the new bone, after central or total necrosis, 
is seldom restored to perfection. The new bone is harder and heavier 
than normal bone (osteosclerosis), but in exceptional cases it remains 
porous and soft (osteoporosis), — a condition described by Yolkmann and 
Schede, which may become the cause of various degrees of deform it}', 
from bending of the shaft. Separation of a sequestrum will take place 
in from four weeks to three months, according to the age of the patient 
and the location and extent of the necrosis*. 

TREATMENT. 

An early and correct diagnosis is of the greatest importance in the 
treatment of acute osteomyelitis. As the gastro-intestinal canal is 
undoubtedly more frequently the route through which infection takes 
place than is generally supposed, and, as nature's resources often attempt 




Fig. 98.— Hollow, Padded, Posterior Splint. (Esmarch.) 



elimination of the pathogenic microorganisms in this direction, it would 
appear rational to administer a brisk cathartic soon after the appearance 
of the first symptoms, as such treatment might prove of great value in 
arresting further infection from this source. A large dose of calomel, 
administered for the same purpose and in the same manner as advised 
during the early stage of typhoid fever, could not fail to produce a salu- 
tary effect. Kocher has advised the internal use of salicylate of soda, 
giving from 6 to 24 grammes in divided doses during twenty-four hours. 
In such doses this remedy would also have some effect in reducing the 
temperature, which is constantly high in all acute cases. Opium must 
be given in sufficient doses to alleviate pain. „ The affected limb should 
be placed in a slightly elevated position. 

Demme, Billroth, and Yolkmann recommend vesication by frequently 
repeated applications of the strong tincture of iodine. It is doubtful if 
such treatment has an}' influence in arresting or even retarding the 
further development of the disease. The use of the ice-bag is rational, 



TREATMENT. 



271 



and often relieves pain. In multiple osteomyelitis, with pronounced 
symptoms of progressive sepsis almost from the beginning of the attack, 
it is doubtful whether any surgical treatment will have any effect in 
preventing a fatal termination. In such cases general infection occurs 
almost from the very beginning, and at the necropsy very little, if any, 




Fig. 99.— Board Splint for Upper Extremity. (Esmarch.) 



pus is found in the inflamed medullary tissue. The indicatio vitalis in 
these cases calls for the use of stimulants. 

One of the most important duties of the surgeon, in taking charge 
of a recent case of osteomyelitis of any of the long bones, is to secure 
rest and elevation of the affected limb. For the lower extremity a 




Fig. 100.— Wire Splint. (Esmarch.) 



hollow, well-padded, posterior splint, shown in Fig. 98, will answer an 
excellent purpose. For the upper extremity a wire or board splint will 
secure the necessary degree of immobilization. Immobilization of the 
limb in proper position from the very beginning of the attack of osteo- 
myelitis is the most efficient prophylactic measure against contractures 



272 



PRINCIPLES OF SURGERY. 



of joints, which follow so often as remote complications. An excellent 
method of immobilization of a limb after an early operation for osteo- 
myelitis consists in the application of an interrupted plaster-of-Paris 
splint, as shown in Fig. 101. The two parts of the plaster-of-Paris splint 
are connected by a posterior wooden splint, which is incorporated in the 
plaster dressing by packing the spaces between the splint and the surface 
of the limb. By painting the splint and its packed margins with shellac 
varnish it is rendered impermeable to antiseptic solutions. 

In regard to the propriety of making early incisions the greatest 
diversity of opinion has prevailed in the past. Previous to the researches 
of Demme, early and free incisions were practiced very generally. As 




Fig. 101.— Plaster of-Pakis Splint. 



the results following the treatment were frequently disastrous, Demme 
was led to adopt a more conservative treatment. He advised an expec- 
tant plan to be pursued until the disease should exhaust itself, as it were, 
as indicated by reduction of temperature and cessation of the active 
symptoms of the inflammation, and then he argued the propriety of 
making large incisions. For the purpose of affording an outlet for the 
pus Klose made early and small incisions at the junction of the epiphysis 
with the diaphysis. Oilier advocates early incision, combined with 
trephining of the bone. In a communication, read before the Academy 
of Paris, he claims that trephining is applicable to all forms of osteo- 
myelitis with severe general symptoms. He maintains that trephining, 



TREATMENT. 273 

even in the most diffuse form, will arrest the intense pain by relieving 
pressure ; and where the disease is circumscribed it affords prompt and 
decided relief. In the acute form, he claims, trephining will often pre- 
vent external necrosis and fatal symptoms, while in the subacute and 
chronic form it removes the most distressing s} r mptom, — pain. In 8 out 
of 19 cases of early trephining he found pus; and in 10 cases the marrow 
presented different morbid appearances ; while in the last case, a case 
of acute osteomyelitis of the femur, a large quantity of fluid blood 
escaped. Two of the 19 cases died of pyaemia. 

Since osteomyelitis has been recognized as a microbic disease, at- 
tempts have been made to arrest the disease by intra-osseous injections 
of germicidal solutions. Hueter has employed parenchymatous injections 
of solutions of carbolic acid with decided benefit in the treatment of 
other inflammatory affections of bones and soft tissues. Kocher recom- 
mended that the soft tissues around the infected bone should be disin- 
fected by saturating them with a solution of carbolic acid, thrown in 
with an ordinary hypodermic syringe. Later, the same author suggested 
the propriety of making intra-osseous injections after penetrating the 
bone with a small perforation and injecting carbolized water, thus reach- 
ing the primary focus of the disease. Theoretically, the suggestion 
appears valuable; practically, intra-osseous injections in the treatment 
of acute suppurative osteomyelitis have proved a failure. If it is next 
to impossible to abort even a small circumscribed suppurative inflamma- 
tion in the soft tissues with antiseptic parenchymatous injections, it is 
not surprising to learn that the same treatment has invariably failed in 
arresting suppuration in the interior of bones. Intra-osseous injections 
are no longer used in the treatment of acute suppurative osteomyelitis. 

Antiseptic surgery has revolutionized the treatment of acute suppu- 
rative osteomyelitis. The diseased medulla is now attacked with the 
same impunity as the soft tissues outside of the bones. The objections 
to large incisions increasing the danger from sepsis and pj^semia are no 
longer well-founded, as incisions made under antiseptic precautions for 
the evacuation of pus, instead of increasing the risks of death from sepsis 
or pyaemia, are now considered the best means to prevent these fatal 
complications. 

It can now be laid down as an axiom in surgery that the medullary 
cavity, in every case of acute suppurative osteomyelitis, should be freely 
exposed and submitted to direct and most thorough antiseptic treatment 
as soon as a positive diagnosis can be made. It would be a serious and 
unjustifiable mistake to open a healthy medullary cavity; but, on the 
other hand, it would also be next to criminal negligence to wait for 
fluctuations before resorting to operative treatment in a case of acute 



274 PRINCIPLES OF SURGERY. 

osteomyelitis. The bone should be opened, the infected medulla removed, 
and the cavity disinfected before suppuration has extended to the peri- 
osteum and the surrounding soft tissues. The intelligence and moral 
courage of a surgeon can be nowhere better tested and gauged than 
when he is confronted by a recent case of acute osteomyelitis. He 
must be sure of his diagnosis, and this often requires no ordinary 
erudition and diagnostic skill. A positive diagnosis made, he must 
possess enough courage to face the popular prejudice against early 
operation under circumstances where success is not always attainable. 
Impressed with the imperative necessity of operative interference from 
his knowledge of a case, a conscientious surgeon will not flinch from his 
duty, even under the most unpromising circumstances. If the respon- 
sibilities and risks are great, he will do well to fortify his course by 
calling into consultation one or more of his colleagues, to protect himself 
against unmerited criticism in the future or, perchance, a suit for mal- 
practice. An early radical operation for osteomyelitis (and the author 
means by this an operation done as soon as a positive diagnosis can be 
made, and before any external swelling has appeared) accomplishes the 
following most desirable results : 1. It removes pain. 2. It enables the 
surgeon to remove the local cause of the disease completely or in part. 
3. It prevents extensive necrosis. 4. It is the best prophylactic measure 
against fatal septicaemia and p3 7 semia. 5. It prevents extensive destruc- 
tion of the periosteum and other contiguous soft parts. 6. It cuts short 
the attack and expedites recovery. 

As we have seen, the pain which attends osteomyelitis is caused by 
the intra-osseous tension and by the secondary periostitis. If the 
medullaiy cavity is opened freely before suppurative periostitis has 
developed, the operation removes the conditions which cause the pain, 
and will therefore accomplish at once what anodynes and external appli- 
cations can do but imperfectly. The removal of the infected tissues 
fulfills the etiological indications of the disease, the removal of the pus- 
microbes complete^ or in part, which, with thorough disinfection of the 
cavity, prevents the further extension of the disease. Necrosis takes 
place from the action of the pus-microbes and their ptomaines on the 
tissues, intra-osseous tension, and vascular obstruction, all of which 
causes are either removed or, at least, favorably modified by an early 
radical operation. Limitation of necrosis is one of the most marked 
results of all early antiseptic operations for acute osteonryelitis. Progress- 
ive sepsis is caused by the introduction of pus-microbes and their 
ptomaines from the osteomyelitic focus into the general circulation ; 
hence, there is no better wa} r in which this fatal complication can be pre- 
vented than by the removal of the infected tissues and subsequent 



TREATMENT. 275 

disinfection of the cavity, followed by efficient drainage and strict anti- 
septic treatment of the wound. As pyaemia is alwa}^s caused by septic 
tlirombo-plilebitis, no surer way of guarding against it could be devised 
than the early removal of the infected tissues, which may include the 
vessels with a beginning tlirombo-plilebitis, If the interior of an osteo- 
myelitic bone is rendered accessible to direct means of disinfection, such 
treatment will often, if not invariably, prevent the extension of the sup- 
purative inflammation to the periosteum and surrounding connective 
tissue, which constantly occurs when the patients are treated upon the 
expectant plan. An early radical operation, by limiting the necrosis and 
extension of the inflammation to the surrounding soft tissues, shortens 
the attack, and is conducive toward establishing at an early time a repar- 
ative process in place of one of destructive. Pathological fractures will 
become less frequent complications in acute osteou^elitis as soon as 
early radical operations are more generally adopted. Early operations 
under antiseptic precautions, in short, are life-saving operations ; at the 
same time, the}'- will leave the parts in a more satis factoiy condition for 
rapid and satisfactory repair. An early operation I should call one done 
before secondary suppurative periostitis has appeared. An intermediate 
operation for acute osteonryelitis is one performed after suppuration has 
occurred around the bone first affected, and late operations are under- 
taken for the removal of necrosed bone. 

Early Operations. — The surface of the limb is prepared in the same 
manner as for other antiseptic operations. The primary focus of the 
disease, usually in the vicinity of an epiphyseal line, is accurately located 
by searching for the most tender point. Over this point, or as near to 
it as the nature of the soft parts will permit, an incision is made down 
to the bone. As the operation is to be done below Esmarch's constrictor, 
the soft tissues can be carefully examined during every step of the 
operation, and their exact condition ascertained. The skin and under- 
lying fascia are cut through with one stroke of the knife, when the knife 
should be laid aside and the remaining tissues, down to the bone, are 
carefully separated with the finger, which can be readily done bj r follow- 
ing the intermuscular septa. The periosteum, even at an early stage, 
will be found vascular and easily separated from the bone. This 
structure is then reflected with the soft tissues on each side, and held 
out of the way with retractors. The bone is then opened with a small, 
round chisel. The trephine should never be used, as it is, to say the 
least, a bungling and inefficient instrument, while the chisel is an instru- 
ment of precision. For the first, or explorator}', opening a semicircular 
chisel should be used ; in the further steps of the operation ordinary 
chisels, such as are used by carpenters, answer an excellent purpose. 



276 PRINCIPLES OF SURGERY. 

As the first opening will probably be made near an epiphyseal extremity, 
at a point where the compacta is very thin, the chiseling is attended by 
no difficulties. The opening is made directly toward the centre of the 
bone. If no pus has formed the osteomyelitic focus is recognized by 
the softness and great vascularity of the tissues and the escape of bloody 
serum. If pus is found it will probably appear at this time as an infil- 
tration. The object of the operation is not only to open the bone, but 
to remove all of the infected tissues. The opening in the bone is, there- 
fore, enlarged in the direction of the shaft to the extent of the disease 
in its interior. If the suppurative inflammation is extensive, involving 
half of the bone, or, perhaps, the entire shaft, it is advisable to make 
several incisions over the bone in the same line instead of one large 
incision, thus avoiding a large wound and, perhaps, injury of important 
structures; at the same time the interior of the bone is rendered accessible 
to direct treatment by opening the bone at the corresponding points and 
scraping out the medullary tissue contained in the intervening sections 
with a sharp spoon, the handle of which can be bent at any desirable 
angle. After the whole cavity has been thoroughly curetted it is dis- 
infected by irrigating it with a solution of corrosive sublimate (1 to 1000), 
and then dried and mopped out with a 10-per-cent. solution of chloride 
of zinc. Peroxide of hydrogen is also an excellent remedy for disin- 
fecting the bone-cavit}^ after curetting. The cavity is then packed with 
iodoform gauze, which is brought out of the wound or wounds to serve 
the purpose of a capillary drain. A copious antiseptic dressing is 
applied, and the limb immobilized in proper position upon a splint. A 
fall in the temperature, and other signs of improvement soon after the 
operation, are indicative that the desired object, primary disinfection of 
the osteomyelitic focus, has been attained. If on the following day the 
temperature show no reduction, the dressings are removed, antiseptic 
irrigations are again employed, and the limb is dressed antiseptically. 
Should, in spite of the early operation and careful antiseptic after-treat- 
ment, the suppurative inflammation extend to the periosteum and the 
connective tissue, the antiseptic occlusive dressing should give way to 
warm compresses kept saturated with one of the mild antiseptic solu- 
tions. Frequent irrigations with a 2-per-cent. boric-acid solution, a J- to 
1-per-cent. solution of acetate of aluminum, or a weak aqueous solution 
of tincture of iodine should be made, and the limb confined upon a 
suspension splint. In 1888 Tscherning recommended very strongly 
early operative interference. He insisted that the bone should be exposed 
and opened in such a manner that the entire infected medulla could be 
scraped out. Karewski operated upon a number of young children in 
accordance with this advice as early as the third day after the beginning 



TREATMENT. 277 

of the initial symptoms, with the result that the disease was cut short 
and necrosis was prevented. 

Intermediate Operations. — If a case of acute osteomyelitis come 
under treatment after purulent infiltration has occurred around the 
affected bone, no time should be lost in evacuating the pus by incision 
and drainage. Multiple incisions and numerous tubular drains are often 
required to effect complete evacuation and secure free drainage. In 
these cases operations on the bone itself should be limited to making- 
small openings in the exposed portion of the bone for the purpose of 
reaching its interior with antiseptic irrigations. Large openings, under 
these circumstances, might lead to pathological fractures. The subse- 
quent treatment is conducted on the same principles as a case of 
phlegmonous inflammation and purulent infiltration of the soft parts. 

As in the early treatment of osteomyelitis by radical operation, the 
limb must be supported in a desirable position by some kind of a splint. 
The use of a proper splint in the treatment of acute osteomyelitis is in- 
dispensable. A well-fitting posterior splint, or the anterior suspension 
splint of R. N. Smith, secures rest for the limb, prevents contractures 
and subluxation of joints, and finally diminishes the frequency of patho- 
logical fractures. Catarrhal synovitis is treated by aspiration, and sup- 
purative synovitis by incision, drainage, and antiseptic irrigations. During 
the acute stage of suppurative osteomyelitis the removal of an entire 
shaft of a long bone should be limited to one bone of the forearm or leg, 
as the removal of the entire shaft of the humerus or femur before the 
formation of an involucrum of sufficient firmness to act as an efficient 
support would greatly complicate the mechanical part of the after-treat- 
ment, and the procedure might result in imperfect restoration of the bone 
removed. Where the greater portion or the entire shaft of a bone has 
become necrosed and has separated at one or both epiphyseal junctions, 
it may become necessary to remove it during the acute stage to avert 
death from exhaustion from profuse discharges and septic fever inci- 
dent to the presence of such a large septic foreign bod}\ It has been 
argued against such a procedure that the bone would not be regenerated 
after its removal. This fear, however, is not supported b} T facts, as when 
the periosteum and the epiphysis remain a good, if not perfect, substitute 
is reproduced. Dupla}^, Holmes, McDougal, Lefort, Giraldes, Spence, 
Petrequin, Wilms, Cheever, Ropes, and Gray have each reported cases 
where almost complete reproduction followed the removal of the entire 
shaft. It is very important, especially in children, to preserve both 
epipfrvses, to prevent subsequent shortening and other deformities of the 
limb. Where the continuity of a bone has been destroj^ed, either by a 
pathological fracture or the removal of a part or an entire diaphysis, 



278 PRINCIPLES OF SURGERY. 

which has separated before the involucrura has become sufficiently firm 
to serve the purpose of an efficient mechanical support, a suitable me- 
chanical support must be applied for a long time to guard against short- 
ening and bending of the new bone. During the septic stage of acute 
osteomyelitis with suppurative synovitis amputation may become neces- 
sary to save the life of the patient. In exceptional cases the same sad 
alternative may become a necessity after the acute symptoms have sub- 
sided, for the purpose of removing the source of exhausting suppurative 
discharges. Our present means of treating abscesses, diffuse purulent 
infiltrations, and suppurative diseases of joints are, fortunately, so perfect 
and efficient that even severe cases can be treated on a more conservative 
plan, and amputation should be restricted to extreme cases as a dernier 
ressort. Should signs of pysemia arise, our main reliance must be placed 
on the administration of large doses of quinine and alcohol. Luecke 
has obtained the best results from large doses of alcoholic stimulants. 
Instances have been reported where two pint-bottles of cognac were 
given during twenty-four hours with decided benefit. Osteomyelitic 
patients should be surrounded by the most favorable hygienic influ- 
ences, as fresh air, equable temperature, light, and an abundance of plain, 
nutritious food. As soon as the acute symptoms have subsided, iron, 
especially tinctura ferri chloridi, should be freely administered. If 
osteomj-elitis is complicated by the co-existence of other diseases, such 
as syphilis, tuberculosis, rachitis, etc., the treatment of the latter should 
receive appropriate attention. 

Late Operations. — As late operations will be considered the oper- 
ative removal of sequestra. The operation for the removal of detached 
dead bone is called necrotomy or sequestrotomy. The operative removal 
of a sequestrum should always be postponed until complete separation 
has taken place and the involucrum is strong enough to furnish the neces- 
saiy mechanical support. If an operation is undertaken at an earlier 
time there is clanger of unnecessarily removing a portion of healthy bone 
or of leaving a part of the sequestrum. Necrosis is not a disease, but 
alwaj's a result of a destructive inflammation. It is not always easy to 
determine whether separation of the sequestrum has taken place in a 
given case. The sinus leading down to the dead bone ma} r be so tortu- 
ous that it is impossible to introduce a probe into the interior of the 
involucrum. Again, if the sequestrum is felt with the probe it is often 
impossible, by any kind of manipulations, to ascertain in this manner its 
mobility, as it is often firmly encased in a bed of granulations. The time 
required in separation of the sequestrum varies greatly, — a whole pha- 
lanx of a finger may be separated completely in four weeks, a cortical 
sequestrum of a long bone may become detached in six weeks to two 



TREATMENT. 279 

months, while the separation of half or an entire shaft of the large long 
bones, as the femur or humerus, may require from three to six months. 
If the patient's general health is improving there is no need of haste in 
the removal of a sequestrum, as there is nothing lost and a great deal 
gained by waiting until sufficient time has elapsed for separation to take 
place. Sequestrotonry, if properly performed, is one of the most grateful 
of all operations, as it is attended by little or no danger to life, and is 
usually followed by a favorable result. Its performance has been greatly 
simplified by the use of anaesthetics and Esmarch's constrictor. 

Since Esmarch taught us how to obtain, by a very simple appliance, 
a bloodless condition of the limb during the operation, the surgeon can 
make the necessary dissection with the same degree of accuracy as in 
the dissecting-room, thus avoiding injury of important vessels and 
nerves, which formerly occurred quite frequently even in the hands of 
the most accomplished surgeons. Before the operation the entire limb 
is disinfected and rendered bloodless by elevating it for a few minutes, 
when an Esmarch constrictor is applied on the proximal side and some 
distance from the seat of operation. I have met, in my practice, with two 
cases of paralysis of the musculo-spiral nerve from the use of Esmarch's 
constrictor, which was applied about the middle of the arm, and, 
although both patients recovered perfect use of the limb in the course 
of two to four months, I have since taken the precaution to guard 
against such a perplexing accident by applying the constrictor over the 
middle of the deltoids, and over several thicknesses of a towel in order 
to protect the nerves against undue pressure. Since I have made use of 
these precautions I have had no further accidents from elastic constric- 
tion. In an operation for extensive necrosis of the tibia the constrictor 
was applied just above the knee, and as soon as the patient recovered 
consciousness it became evident that the constriction had resulted in 
paralysis of the peroneal nerve. More than four months elapsed before 
function was completely restored. Since that time I always apply the 
constrictor higher up, where the nerves are protected by a thick cushion 
of muscular tissue, and have seen no more evil effects from elastic con- 
striction of the lower extremity. Wherever it is safe to make the 
incision in the line of one or more fistulous openings this should be 
done, but when these are in localities where there would be danger of 
wounding important vessels, muscles, or nerves, another location must 
be chosen. In operations upon the humerus the exact location of the 
musculo-spiral nerve must be remembered, and if the incision necessarily 
come close to this structure the dissection is made slowly and with the 
use of blunt instruments until the nerve is found, when it can be held 
out of the way. In operations upon the lower end of the femur, even 



280 



PRINCIPLES OF SURGERY. 



if the fistulous opening should be in the popliteal space, the incision down 
to the bone should be made in the course of the intermuscular septum, 
on the outer or inner side, as the posterior surface of the femur can be 
made accessible from either side by making the incision large and by 
keeping close to the bone, separating the soft tissues well and keeping 
them out of the way b}^ the use of retractors. Where the bone is cov- 
ered by thick layers of muscles the incision is made in the direction of 

the muscles, and at a point 



/,:, /; V .',-■■ >, 




corresponding to an intermus- 
cular septum. In operations 
for neurosis of the shaft of the 
tibia I now invariably employ 
the S-shaped incision, as it 
affords more room and can be 
sutured with less difficulty than 
a straight incision. The ex- 
ternal incision should always 
be large, so as to afford plenty 
of space. As soon as the inter- 
muscular septum is reached 
the scalpel should be laid aside 
and the parts carefully sepa- 
rated down to the bone by 
using the fingers or blunt in- 
struments. When the bone 
is reached the periosteum is 
incised and reflected with the 
soft tissues attached to it. 
The opening of the involucrum 
is done with the chisel. In 
old-standing cases the involu- 
crum is as dense as ivory and 
the chiseling is an exceedingly 
slow and laborious process, as 
only very small chips can be 
removed with each cut of the chisel. The brittleness of the new bone 
should warn the surgeon to chisel with care, as otherwise a fracture 
might result. If the chiseling is done at the site of a former opening, 
this opening is enlarged until the sequestrum is reached and can be 
extracted. Extraction of the sequestrum was the sole object of oper- 
ations in the past ; hence the dead bone was removed through a compara- 
tively small opening in the bone, either in toto or after fragmentation. 



Fig. 102.— Incision for Neurotomy of 
the Tibia. 



TREATMENT. 



281 



Modern surgery not only seeks to remove the dead bone, but to place the 
cavity in the best possible position for rapid healing. The first indica- 
tion to be fulfilled in securing a favorable reparative process after the 
operation is to obtain an aseptic condition of the cavity. This can only 
be done by exposing the interior of the entire cavity. Chiseling is con- 
tinued until both ends of the cavity are reached, when the sequestrum 
can be lifted out and the granulations lining the cavity are scraped out 
with a sharp spoon. Sharp spoons of 
different sizes should be at hand, as the 
interior of such cavities usually presents 
depressions and sinuses which can only 
be dealt with successfully by keeping on 
hand different-sized spoons. After the 
mechanical removal of the infected tis- 
sues the cavity is washed out with a 
solution of corrosive sublimate (1 to 1000) 
and rubbed out and dried with an anti- 
septic sponge. It is evident that the 
healing of such a cavity, by unaided re- 
sources of nature, would be a slow process. 
Various attempts have been made to over- 
come the difficulties in the healing of 
cavities with unyielding walls. D. J. 
Hamilton has suggested sponge-grafting. 
Neuber made flaps of the skin from each 
side, which he fastened to the floor of the 
cavity with sutures or bone nails (Figs. 104, 
105.) Schede utilized the blood, which he 
allowed to accumulate in the cavity after 
suturing the external parts, and obtained 
some excellent results with this treatment. 
Recently, E. Halm advised the detaching 
of the skin on each side to within an inch, 
at the posterior surface of the limb, for 

the purpose of better immobilization of the flaps, which are to be mitted 
over the centre of the gutter by suturing. For a number of years the 
author has been experimenting on animals with decalcified bone in the 
healing of aseptic bone-cavities, and the experimental as well as the 
clinical results obtained so far exceed all expectations. The decalcified 
bone-chips are preserved in an alcoholic solution of corrosive sublimate 
(1 to 500) or a solution of iodoform in sulphuric ether. The most essen- 
tial condition for success, in the treatment of bone defects by implanta- 




Fig. 103.— Bone-Cavity after Re- 
moval, of Sequestrum and 
Granulations in Necrosis 
of the Tibia, after Esmarch. 



282 PRINCIPLES OF SURGERY. 

tion of decalcified bone, is a perfectly aseptic condition of the tissue to 
be brought in contact with the implanted bone. This condition is easily 
procured in operations on bones for lesions other than those caused by 
infection with pus-microbes, such as tumors, echinococcous cysts, and 
tuberculous and syphilitic affections uncomplicated by suppuration. In 
the surgical treatment of these affections, after the removal of the dis- 
eased tissue the seat of operation must be aseptic, if the ordinary pre- 
cautions in the prevention of infection from without have been observed. 
In such cases speedy healing of the external wound and the early partial 
or complete reproduction of the lost bone are assured. The next most 
favorable cases for this procedure are circumscribed osteom3'elitic proc- 
esses in the epiphyseal extremities of the long bones, as we observe them 
in cases of primary circumscribed epiphyseal osteomyelitis, or in the 
form of a recurring attack in the same place, perhaps years after a diffuse 
osteomyelitis of the entire shaft. This method of treating bone-cavities 
is also applicable after operations for necrosis resulting from a previous 





Fig. 104.— Inversion of Soft Tissues Fig. 105.— Healing of Bone-Cavitt, 
on Each Side into the Bone- after Neuber. 

Cavity, after Neuber. 

attack of acute suppurative osteomyelitis. The cavity must be prepared 
for the implantation of decalcified bone in the manner described above. 
The implantation is made before the removal of the constrictor, in order 
that, after this is done, sufficient blood will escape to fill the spaces be- 
tween the chips, and thus serve the useful purpose of a temporary cement- 
substance. After the cavity has been dusted over lightly with iodoform, 
the chips, which have been washed previously in an antiseptic solution, 
are dried upon a gauze compress, and are then poured into the cavit\ r 
until this is packed with them as far as the periosteum. The first advan- 
tage derived from this method of bone-packing is that the chips serve as 
an antiseptic tampon which arrests the free oozing from the surface of 
the bone, which always takes place after the removal of the constrictor. 
Some blood escapes between the bone-chips and coagulates at once, thus 
forming a desirable and useful cement-substance which permeates the 
entire packing, and temporarily glues, as it were, the chips together and 
the entire mass to the surrounding tissues. The periosteum should be 
carefully preserved in exposing the bone, and, after implantation, is 



TREATMENT. 283 

sutured over the surface of the bone-chips with absorbable, aseptic, buried 
sutures. If the bone is deeply located, it may become necessary to 
apply a second and third row of buried sutures in bringing into accurate 
apposition other soft parts. The skin is finely sutured with silk. It is 
of the greatest importance to secure accurate apposition of the divided 
soft parts, in order to preserve for the subjacent bone all of its natural 
coverings. In some instances it would be, undoubtedly, superfluous to 
secure any form of drainage, as, when the cavity is perfectly aseptic and 
haemorrhage is not in excess of requirements, healing of the entire wound 
would be accomplished under one dressing. Experience, however, has 
taught me that tension arising from extravasation of blood often exerts 
an injurious influence upon the process of healing, and should be care- 
fully avoided. As it is desirable to heal as much of the wound as pos- 
sible without interfering with drainage, an absorbable capillary drain 
should be inserted in the lower angle of the wound. A string of catgut 
twisted into a small cord answers an admirable purpose. The wound is 
covered with a strip of aseptic protective silk, over which a few layers 
of iodoform gauze are applied. Over this a cushion of sublimated moss 
is placed, with a thick layer of salicylated cotton along its margins for 
the purpose of guarding more securely against the entrance of unfiltered 
air. The whole of the dressing is retained by a circular gauze bandage, 
evenly and smoothly applied. For the purpose of securing absolute rest 
for the limb it is placed upon a posterior splint and kept in a slightly 
elevated position. If no indications arise the first dressing is not 
removed for two weeks, when the entire wound will usually be found 
healed except a few granulations at the place where the catgut drain was 
inserted. A smaller antiseptic compress is applied and the limb dressed 
in a similar manner. It is prudent to enforce rest, — not only till the 
external wound has healed, but until the process of repair in the interior 
of the bone has been completed, which embraces a period varying from 
four weeks to three months, according to the size of the cavity and the 
age of the patient. If an operation for necrosis with implantation of 
decalcified antiseptic bone-chips is followed by suppuration, it is an evi- 
dence that antisepsis was imperfect, and such cases must be treated upon 
the same principles as suppuration in other localities. If suppuration 
take place soon after the operation, and is profuse, it is probable that all 
of the bone-chips will have to be removed in order to facilitate the dis- 
infection of the cavity. If it develop after granulation tissue has had 
time to form, and the discharge of pus is moderate in quantity, the pros- 
pects are that the bone will remain and serve its purpose as a nidus for 
the granulation tissue. In such cases an antiseptic irrigation should be 
made every three or four days until suppuration has ceased. If the 



284 



PRINCIPLES OF SURGERY. 



bone-chips are lost by suppuration, or have to be removed for the pur- 
pose of a more thorough disinfection of the cavity, no attempt should 
be made at re-implantation until suppuration has been arrested ; or, in 
other words, until the cavity has become lined with granulations and is 
in a comparatively aseptic condition (when the time for secondary im- 
plantation has arrived). After the cavity has been irrigated with a strong 
antiseptic solution the superficial granulations are removed with a sharp 
spoon, and it is packed with bone-chips, which are implanted in the same 
manner as in the treatment of a recent cavity. 

Complete closure of the external wound 
under these circumstances is seldom obtainable, 
and the surface of the exposed portion of the 
cavity should be provided with a thin layer 
of Schede's moist blood-clot. I have resorted 
to implantation of decalcified antiseptic bone- 
chips in the treatment of bone-cavities, after 
necrotomy and operations for tuberculosis of 
bone, in at least 25 cases, and have had the 
satisfaction of healing large defects without a 
drop of pus under one or two dressings in 
from two to four weeks. Only in a small per- 
centage of the cases was it found necessary to 
remove the packing, and in most of these 
secondary implantation proved successful. 
Schede's blood-clot does not possess any anti- 
septic properties, like the bone-chips, and is 
not as permanent a structure. Operations by 
Neuber's method are often followed by necrosis 
of the flaps, and even if successful the lost bone 
is not restored. Implantation of decalcified 
antiseptic bone-chips, in the treatment of 
aseptic bone-cavities, is preferable to the use 
of viable grafts, as the substance used is not 
only absolutely aseptic, but possesses also valuable antiseptic proper- 
ties, which must be looked upon as a valuable and very important 
quality in the treatment of such cases. Reproduction of bone follows 
almost to perfection in every case where antisepsis proves successful ; 
hence they serve the same purpose as viable grafts, as far as the resto- 
ration of lost tissue is concerned. I have chiseled a wide gutter in 
the humerus and tibia, almost from one epiphysis to the other, for the 
removal of large sequestra, and have seen such enormous defects restored 
after implantation with bone-chips in a few weeks. The contour of the 




Fig. 106. — Osteoplastic 
Necrotomy, after Bier. 



CHRONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. 285 

bone is restored to such perfection that after a few months it would be 
difficult to tell where the operation was performed. The bone-chips 
serve as a temporary scaffolding for the granulations springing from all 
sides of the bone-cavity, and as they are removed by absorption their 
place is occupied by living permanent tissue ; first by embryonal cells, 
which are later converted into bone. 

Bier has recently devised an osteoplastic operation for the removal 
of sequestra from superficial bones like the tibia. The incisions down 
to the bone are made in the- usual manner. The two transverse cuts 
through the involucrum are made with a key-hole saw and the longi- 
tudinal section with the chisel. With an elevator the bone is raised with 
the overlying soft tissues, like the lid of a box, thus freely exposing the 
interior of the involucrum. After the removal of the dead bone and 
granulations the flap is replaced and sutured. This operation, is unnec- 
essarily severe, difficult, and tedious, and the disadvantages more than 
overbalance its advantages. 

CHRONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. 

This is the bone-abscess of the older authors. The etiology of this 
form of suppurative inflammation is the same as in the diffuse variety. 
Clinically, two kinds can be distinguished : 1. Primary epiphyseal 
circumscribed osteomyelitis. 2. Secondary circumscribed osteomyelitis. 
The first kind is occasionally met with as a multiple affection, and is 
then attended by more or less constitutional disturbances and may result 
in epiphyseotysis. The secondary form occurs in bones that have been 
the seat of an attack of diffuse suppurative osteomyelitis, the patient 
apparently having recovered completely from the primary attack years 
before. It is still a question under discussion if in these cases the 
infection is caused by microbes which have remained in the tissues in a 
latent state since the primary attack or whether it is caused b} r localiza- 
tion of pus-microbes in the tissues weakened by the first attack. Rosen- 
bach is of the opinion that recurring attacks of osteomyelitis in the same 
bone are caused by pus-microbes which have remained in the tissues, and 
which again become pathogenic when the tissues around them are 
rendered susceptible to their action by subsequent causes. I am 
strongly inclined to the same opinion. I have seen numerous cases 
where, in persons from 16 to 25 years of age, repeated attacks of circum- 
scribed osteomyelitis occurred in a bone which, during childhood, had 
passed through an attack of acute osteomyelitis. The tibia, femur, and 
humerus are the bones which are most frequently attacked by recurrent 
osteomyelitis. The secondary attacks occur either in the centre of the 
sclerosed bone, the former site of the infected medullary cavitj r , or near 



286 PRINCIPLES OF SURGERY. 

one of the epiphyseal lines. I have no doubt that secondary osteo- 
myelitis will be of less frequent occurrence after early operations for 
osteomyelitis, and that antiseptic sequestrotomy will be more generally 
practiced. 

Symptoms. — The most important symptoms of circumscribed central 
suppuration in bone are pain and tenderness. The pain is deep-seated, 
intense, of a boring or gnawing character, and is generally more severe 
after active exercise and during the night. It is often intermittent, and 
has frequently been wrongly interpreted as neuralgia of bone. 

The tenderness is circumscribed, and corresponds to the location of 
the suppurating focus. It is due to a circumscribed secondary plastic 
periostitis. The external swelling is slight, and often completely wanting. 
Usually neither redness nor oedema is present. 

Pathological Anatomy. — Limited suppurative osteomyelitis gives rise 
to a circumscribed abscess, which varies in size from a pea to a walnut. 
Necrosis of bone seldom takes place ; if it does the sequestra are small 
and composed exclusively of cancellated tissue. If the abscess is situated 
in an epiphysis it may open into the adjacent joint and become the cause 
of a secondary suppurative arthritis. Thrombo-phlebitis, sepsis, and 
P3'aeinia rarely occur. The periostitis which attends chronic suppuration 
in bone alwaj's assumes a plastic type, as the periosteum is bej^ond the 
reach of pus-microbes. Epiphyseal osteomyelitis is often associated with 
chondritis and osteoporosis, — conditions which may result in pathological 
fracture. If in this form of osteonryelitis the suppuration extend to 
the periosteum, a circumscribed suppurative periostitis occurs, which is 
followed by the formation of small abscesses in the epiphyseal region. 
Limited necrosis in these cases is of frequent occurrence. 

Treatment. — Circumscribed osteomjelitic processes in the epiphj's- 
eal extremities of the long bones, as we observe them in cases of primary 
circumscribed suppuration in the epiphyseal region, or in the form of a 
recurring attack in the same place or in the sclerosed shaft, perhaps 
3 T ears after a diffuse osteon^elitis of the entire shaft, are favorable cases 
for implantation of decalcified antiseptic bone-chips, as an aseptic con- 
dition of the cavit}' can be readily procured after the operative removal 
of the infected tissues. The inflammator} r focus can be located externally 
with accuracy by the presence of a circumscribed area of tenderness, 
and the centre of the tender spot constitutes the guide in the search for 
the abscess. The operation is performed under strict antiseptic precau- 
tions, and by the bloodless method. The chiseling is done in the direc- 
tion of the centre of the bone by making a track perhaps an inch square. 
If the abscess is not found at a certain depth the surrounding tissue is 
explored with a small drill in different directions from the track, until 



CHRONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. 287 

it is discovered, when further excavation is again made with the chisel. 
As soon as the abscess has been fully exposed the pus is washed out 
and the size of the cavity ascertained by probing. As the abscess is 
often surrounded by a zone of tissue infiltrated with pus, all of the 
infected tissues are scraped out thoroughly with a sharp spoon ; after 
which the cavity is prepared for the implantation of the bone-chips in 
the same manner as in operations for necrosis. Iodoformizatiou of the 
cavity and the implantation of antiseptic bone-chips are measures which 
are well calculated to resist the pathogenic action of pus-microbes which 
might still remain, and in the majority of cases will secure an aseptic 
healing of the wound. I have repeatedly seen cavities the size of a 
small orange, in the head of the tibia, heal under two dressings with 
perfect restoration of the bone removed by this method of treatment. 
The means resorted to to obtain an aseptic condition of the cavity will 
often result in increase to twice its original size, but the loss of tissue 
is not to be taken into consideration when a method of treatment is to 
be employed which requires perfect asepsis in order to be successful in 
placing the parts in a condition where perfect restoration will be 
accomplished with almost unfailing certainty. 



CHAPTER XII. 

Suppuration in Large Cavities; Abscess of 
Internal Organs. 

The suppurative affections of the different large cavities in the body 
present so many features common to all of them that they will be con- 
sidered together in this chapter. Suppurative inflammation of a mem- 
brane, synovial or serous, lining a closed cavity, is characterized by the 
rapidity with which the inflammatory process spreads over the entire 
surface, and the retention of the products of inflammation in a preformed 
closed space. Abscesses of internal organs result from infection by the 
extension of a suppurative lesion from the surface along the course of 
blood-vessels, lymphatics, nerve sheaths, or by the localization of pus- 
microbes floating in the blood in a locus minoris resistentiae of an organ. 

suppurative arthritis. 

Suppurative inflammation in an intact joint is always caused by 
localization ol pus-microbes in the synovial membrane, conveyed to this 
structure by the blood, which results in suppurative synovitis, and, by 
the extension of the infection to the other structures of the joint, is 
often followed by complete disorganization of the joint. In this manner 
metastatic suppurative synovitis is caused, as it occurs, in pyaemia, 
gonorrhoea, and in some of the general infective diseases. 

Bacteriological Researches. — Tn animals susceptible to the action 
of pus-microbes, the injection into a joint of a pure culture is usually 
followed by acute suppuration, and, not infrequently, by the formation 
of extensive para-articular abscesses. HofTa, Kranzfeld, and Krause have 
studied, with special care, the microbic origin of suppurative syno- 
vitis, and all of them found in the pus one or more varieties of the 
microbe of suppuration. Krause found, in the pus of suppurating joints 
in small children, a streptococcus the identity of which with the one 
described, by Rosenbach was proved by cultivation experiments. In 
one case the same microbe was also found in the products of a purulent 
meningitis, which followed in the course of the joint disease. The same 
streptococcus was found by Hiiber and Bahrdt in pus from a suppurat- 
ing joint, and in the diphtheritic membranes of a scarlet-fever patient. 
The so-called gonorrhoeal rheumatism is a suppurative synovitis, but 
opinions are divided in reference to the pyogenic properties of the 
gonococcus. The microbe was discovered in gonorrhoeal pus by Neisser, 
in 1879. Its direct etiological relation to gonorrhoea has been sufficiently 
demonstrated by experimental research and clinical observation. The 
gonococcus alwa}^s occurs in pairs, and is, therefore, a diplococcus. 

(288) 



SUPPURATIVE ARTHRITIS. 289 

The cocci appear as hemispherical bodies, with their flattened sur- 
faces in apposition, which imparts to the microbe the characteristic 
biscuit-shaped appearance. They are found in clusters upon, or, what 
is more probable, as Bumm asserts, within the pus-corpuscles of gonor- 
rheal pus. Their intracellular location was shown by Bumm, by exam- 
ining pus-corpuscles in water ; when, after imbibition of fluid, the cells 
became swollen, the cocci could be seen between the molecular granules 
of the protoplasm. The microbes within the corpuscles may become so 
numerous as to fill the entire space, with the exception of the nucleus. 
It can be cultivated upon solidified blood-serum or agar-agar-meat 
peptone. Its pus-producing property in specific inflammation of the 
mucous membrane of the urinary organs and conjunctiva is well known, 
and at present is not attributed to its direct effect on the tissues, but to 
the action of the toxins which it produces. A number of cases have 
been reported which appear to show that under certain circumstances 






Fig. 107.— Gonococcus. (Bumm.) 

A. From a pure culture. B. From a bleunorrhoeic conjunctival secretion ; an epithelial cell covered 
with cocci; a pus-corpuscle with cocci in the protoplasm; a pus-corpuscle completely tilled with cocci; 
a free mass of cocci in close proximity to a pus-corpuscle. C. Development of gonococci. 

the microbe enters the circulation and becomes the cause of metastatic 
suppuration, especially in joints. Schwarz asserts that the gonococcus 
is constantly found in the effusion of joints in gonorrhoeal rheumatism, 
in other abscesses caused by gonorrhoea, and in the glands of Bartholin, 
in women who have passed through an attack of gonorrhoea. Petrone 
detected the gonococcus in the effusion of joints and in the blood, in 
two patients suffering from gonorrhoeal rheumatism. He regards the 
joint-complications as metastatic processes caused by the gonorrhoeal 
infection. Other authors found metastatic abscesses in gonorrhoeal 
patients, cultivated from the pus-microbes of suppuration, and on this 
account regard them as the result of a secondary or mixed infection. 
If gonococci can transform epithelial cells of the urethra or conjunctiva 
into pus-corpuscles, there is no reason to doubt that under favorable 
circumstances they can exercise the same pathogenic effect on other 
tissues, particularly the synovial membrane of joints. 

Symptoms and Diagnosis. — Suppurative arthritis is usually attended 

19 



290 PRINCIPLES OF SURGERY. 

by a great deal of pain. This symptom is a prominent one in this affec- 
tion on account of the intensity of the inflammation, and also because 
the pus accumulates with great rapidity in the joint, causing tension. 
Nocturnal exacerbations are common. The pain is greatly aggravated 
by passive motion, and any attempt on the part of the patient to use the 
joint vastly increases the suffering. Flexion of the joint is an early 
symptom, and increases in degree with the progress of the disease. In 
suppurative inflammation of the hip- and knee-joints it is not uncommon 
to find the limb fixed at right angles. In advanced cases of suppura- 
tive gonitis the tibia becomes partially dislocated backward and rotated 
outward. The swelling, as long as it is caused by the effusion into the 
joint, is proportionate to the amount of fluid contained in the joint. In 
the knee-joint the patella is raised from the condyles of the femur, the 
depressions on each side of it are effaced, and the upper recesses of the 
synovial sac become prominent. After perforation of the capsule the 
pus escapes into the loose para-articular connective tissue, where it 
causes a rapidly spreading phlegmonous inflammation. In very acute 
cases rupture of the capsule and an extensive para-articular abscess may 
appear in less than a week. With the rupture of the capsule of the joint 
the pain is diminished, but the general symptoms are aggravated. The 
parts around a suppurating joint usually present an cedematous appear- 
ance. The clinical history is often of great value in arriving at a con- 
clusion in reference to the character of the sj^novitis. If an arthritis 
develop insidiously in connection with a suppurating lesion, attended 
by grave general symptoms, it is an evidence which renders a diagnosis 
of p3 T semia more than probable. In pyaemia the joint affections appear 
often, either simultaneously or in rapid succession, as multiple affections. 
An obstinate joint affection, appearing in the course of an attack of 
gonorrhoea, is generally either a sero-purulent or suppurative synovitis. 
Gonorrhceal sj'iiovitis develops most frequently from the second to the 
fourth week after the appearance of the primary disease. If any doubt 
exist as to the character of the effusion into a joint, this can be readily 
dispelled by making an exploratory puncture with an ordinary hypo- 
dermatic needle. 

Treatment. — The only form of suppurative synovitis amenable to 
any other treatment, short of free incision, drainage, and antiseptic irri- 
gation, is the sero-purulent effusion complicating gonorrhoea. In such 
cases aspiration, followed by compression of the joint and fixation of 
the limb in an immovable dressing, is usually successful in permanently 
removing the effusion. In gonorrhceal joints and in joints the seat of 
secondary infection in p3 T aemic patients I have obtained very satisfactoiy 
results from repeated tapping followed by injection with a 5-per-cent. 



SUPPURATIVE ARTHRITIS. 291 

solution of carbolic acid. The absorption of the products of inflammation 
and return of function are hastened by massage and hot and cold douches. 
If a joint contain pus temporizing measures should be abandoned, and 
the pus should be evacuated either by aspiration followed by washing 
out with an antiseptic solution, which should be repeated until the fluid 
returns clear, or, what is preferable in the vast majority of cases, the 
joint is treated from the beginning as an ordinary abscess. For irriga- 
tion of a suppurating joint with the aspirator, a J-per-cent. (.5 per cent.) 
solution of acetate of aluminum should be used. The greatest care must 
be exercised not to inject atmospheric air into the joint, as, aside from 
the danger of increasing the affection by the admission of air, such acci- 
dents have been followed by immediate death from air-embolism. The 
most efficient treatment in cases of suppurative arthritis is incision and 
drainage under strictest antiseptic precautions. As in the treatment of 
acute abscesses, the incisions must be made in places where drainage is 
most required. A long pair of haemostatic forceps is an indispensable 
instrument in draining a joint. In draining the knee-joint three trans- 
verse tubular drains should be inserted, — one beneath the tendon of the 
patella, one under the patella, and one across the upper recess of the 
joint. The fourth drain should be passed directly through the joint 
between the condyles of the femur, reaching from one side of the patella 
into the popliteal space. This would require eight incisions, each from 
J to 1 inch in length ; half of them serve as openings into the joint for 
the forceps, while in making the remaining incisions only the skin and 
fascia are cut to the requisite extent over the point of the forceps. In 
tunneling the soft tissues in the popliteal space, with the forceps, from 
within outward, the opening is to be made to one side of the large vessels 
and nerves. Such an operation requires the administration of an anaes- 
thetic and the use of elastic constriction of the limb. 

As soon as all the drains are inserted the joint is washed out in 
different directions with one of the stronger antiseptic solutions, after 
which a copious antiseptic dressing is applied and the limb is immobil- 
ized upon a splint. If on the following day the fever has not subsided, 
or as soon as the dressing has become saturated with the discharges, it 
is removed and the irrigation repeated as before. As soon as suppura- 
tion diminishes, through drainage is dispensed with and the drains are 
shortened from time to time, to be entirely removed with the disappear- 
ance of the swelling and the cessation of suppuration. The elbow-joint 
can be efficiently drained by passing a drain transversely through the 
joint, between the articular surfaces of the humerus, radius, and ulna. 
In draining the ankle-joint a small incision is made down into the joint, 
at a point corresponding to the anterior margin of the external malleolus, 



292 PRINCIPLES OF SURGERY. 

through which a haemostatic forceps is introduced and pushed in a 
backward direction, along the upper surface of the astragalus, until its 
point can be felt posteriorly under the skin, to the outer side of the 
tendo Achillis. The skin is then incised, the opening enlarged by un- 
locking the forceps and separating its blades, and a fenestrated rubber 
drain drawn through. If, as it so often happens, the posterior portion of 
the capsule of the joint bulge considerably, this can be drained by a 
drain inserted transversely underneath the tendo Achillis, near its attach- 
ment to the os calcis. Through drainage of the shoulder-joint in an 
antero-posterior direction can be established in the same manner without 
much difficulty. Drainage of the hip-joint is always difficult and never 
efficient. The best plan to follow is to open the joint from behind 
through an incision three or four inches in length, and then to pass a 
long pair of Pean's or polypus forceps between the capsule and the neck 
of the femur, either along the upper or lower border, in the direction of the 
groin, and to make a counter-incision upon the point of the instrument, 
and to draw a tubular drain through the whole length of the track. The 
wrist-joint can be drained transversely and antero-posteriorly, without 
fear of injuring any important structures. If suppuration continue, in 
spite of free drainage and careful antiseptic after-treatment, threatening 
the life of the patient from exhaustion or sepsis, more aggressive measures 
are indicated. Under such circumstances, it becomes often an exceed- 
ingly difficult matter to decide which one of the operative procedures 
should be adopted, — arthrectomy, excision, or amputation. If the pa- 
tient's strength is so much reduced that arthrectomy or excision offer no 
prospects of a successful issue, amputation should be performed. This 
alternative becomes an unavoidable necessity if the suppurative arthritis 
is complicated by extensive burrowing of pus among the muscles, ten- 
dons, and para-articular tissues. If the patient's strength warrant an 
arthrectomy, this operation should be done if the disease is limited to the 
synovial membrane of the joint. Typical or atypical resection is to be 
restricted to cases where the articular cartilages and bone itself are found 
diseased. In resection of joints for suppurative affections, the surgeon 
must aim to remove only infected tissues ; hence incomplete at} T pical are 
more frequently indicated than complete or t} 7 pical resections. All 
cases of suppurative inflammation of joints should be treated from the 
beginning by immobilization of the limb and by the use of an appro- 
priate mechanical support, both for the purpose of securing rest and to 
prevent deformities. 

ENDOCRANIAL SUPPURATION. 

(a) Suppurative Pachymeningitis. — Suppurative inflammation of the 
dura mater occurs either as a circumscribed or diffuse affection. It is 



ENDOCRANIAL SUPPURATION. 293 

caused by direct or indirect infection with pus-microbes. Direct infec- 
tion occurs when the membrane is in communication with an infected 
penetrating wound of the skull. Traumatism, without infection, never 
results in suppurative inflammation of the envelopes of the brain ; nor 
does the presence of an aseptic foreign body produce it. Aseptic 
injuries of the brain and its envelopes are productive of circumscribed, 
degenerative, or plastic lesions, but no suppuration. Septic inflamma- 
tion of these structures, on the other hand, is noted for its tendency to 
become diffuse and to extend from one tissue to another, both by con- 
tinuity and contiguity. Thus, in cases of pachymeningitis with loss of 
continuity of the dura mater, in cases of compound fractures of the 
skull, resulting from infection with pns-microbes from without, the in- 
flammation commences upon the outer surface of the membrane, and if 
the pus-microbes do not penetrate the tissues the suppurative process 
remains superficial ; but, as is more frequently the case, the microbes 
wander deeper into the tissues, until the entire thickness of the dura has 
become infected, and when the inner surface is affected, the underlying 
membranes, the arachnoid and pia mater, as well as the surface of the 
brain itself, are liable to become involved, step by step, by the extension 
of the infection from membrane to membrane and surface to surface. 
Suppurative paclrymeningitis may remain as a circumscribed affection, 
and, if the internal surface of the dura is the seat of suppuration, it 
results in the formation of a subdural abscess. In circumscribed sub- 
dural suppuration, the diffusion of the pus between the dura mater and 
the arachnoid is prevented by a plastic exudation, which cements the 
two membranes together. In suppurative pachj'meningitis, affecting 
only the inner surface of the dura, we often find a subcranial abscess, 
the outer wall of which is formed by the skull and the inner by the 
dura mater. The mechanical effect of the presence of pus in either 
locality will give rise to the same group of cerebral symptoms. Indirect 
infection of the dura mater with pus-microbes occurs in cases of suppu- 
ration in the epicranial tissues and in suppurative osteomyelitis of the 
cranial bones, b}^ extension of the infection along the course of blood- 
vessels. In this way an insignificant peripheral suppurative lesion of 
the coverings of the skull is often followed by a grave form of endo- 
cranial suppuration. 

Symptoms and Diagnosis. — Diffuse septic pachymeningitis is always 
attended by inflammation of the arachnoid, pia mater, and cortex of the 
brain, and the symptoms point more toward a cortical encephalitis than 
a pachymeningitis. Localized suppurative pachymeningitis gives rise to 
symptoms which indicate the presence of a phlegmonous inflammation, 
modified in this instance by symptoms arising from mechanical disturb- 



294 PRINCIPLES OF SURGERY. 

ances, caused by the presence of inflammatory exudation, or the partici- 
pation of the surface of the brain in the suppurative process. In the 
acute septic form, following a compound fracture of the skull, the first 
symptoms are observed, usually, during the second or third day after 
the injury, and rapidly increase in intensity from the progressive exten- 
sion of the infection. In the circumscribed form the sjmptoms are 
more localized. The headache is often severe, especially if the inflam- 
mation is located upon the inner surface of an intact dura, and involves 
a corresponding extent of the subjacent membranes and cortex of the 
brain. The early symptoms are those of irritation, to be followed, as 
the accumulation of pus increases, by evidences of compression. By 
means of focal symptoms it is often possible to locate the seat of the 
inflammatory product in the interior of an intact skull with sufficient 
accuracy to enable the surgeon to evacuate the pus by operative measures. 
Acute suppuration between the surface of the brain and the inner sur- 
face of the skull is always attended b}^ a rise in the temperature. The 
pulse is accelerated, at first full and bounding, to become slower and 
slower as compression increases. If the pulse, in a case of endocranial 
inflammation, has been gradualty reduced from 120 to 35 or 40, it is 
a sign that cerebral compression has reached the maximum extent com- 
patible with life, and when it again reaches its former frequency it is an 
indication that dissolution is near at hand. The condition of the dura 
mater in subdural suppuration is of great importance in determining the 
presence or absence of accumulation of pus. In compound fractures, 
with loss of bone-substance, the existence of a subdural abscess is indi- 
cated by bulging of the dura into the opening of the skull and absence 
of cerebral pulsations. In trephining the skull for a supposed endo- 
cranial abscess, the surgeon's dmVy is to explore the subdural space, or 
to incise the dura mater, if this membrane appear tense or bulge into the 
opening, and if cerebral pulsations cannot be seen or felt. 

Treatment. — The successful prevention of endocranial infection by 
rigid antiseptic precautions in compound fractures of the skull and endo- 
cranial operations is one of the best arguments in support of the value 
of the antiseptic treatment of wounds. Intentional opening of the 
skull under strict antiseptic precautions is seldom followed by suppura- 
tive endocranial inflammation. Compound fractures of the skull without 
fatal injury to the brain, if treated by strict antiseptic measures soon 
after the receipt of the injury, generally result in recoveiy of the patient. 
The most important indication in the treatment of these cases is to 
prevent infection of the wound, and thus guard most effectively against 
the occurrence of endocranial suppuration. 

In the treatment of compound fractures of the skull, correction of 



ENDOCRANIAL SUPPURATION". 295 

mechanical difficulties is nothing compared with the importance of carry- 
ing out full antiseptic precautions to prevent the fatal complications. 
Suppurative pachymeningitis is prevented by the same treatment which 
secures an ideal aseptic healing in wounds of other parts. The prophy- 
lactic treatment aims at obtaining for the external wound, the fractured 
bones, and the exposed spaces underneath them a perfectly aseptic con- 
dition. The entire head should be shaved and the scalp rendered 
aseptic, by washing it with warm water and potash-soap, to be followed 
with a solution of corrosive sublimate (1 to 1000), and, lastly, with sul- 
phuric ether or alcohol. The wound of the pericranial tissues is en- 
larged sufficiently to admit of thorough disinfection of the crevices 
between the fragments. Blood-clots and other foreign substances are 
to be sought for and removed, as infection is often traceable to imperfect 
treatment in this regard. Loose fragments are removed and kept in a 
warm solution of corrosive sublimate until they are re-implanted. De- 
pressed fragments are elevated, and the space between the bone and the 
dura disinfected. If the dura has been lacerated the disinfection is 
carried farther. Detached and contused brain-tissue is removed. All 
haemorrhage is carefully arrested, and after the final irrigation the dura 
is sutured, and, if necessary, a capillary drain of aseptic catgut or 
horse-hair inserted. 

In the majority of cases it is advisable to drain the external wound 
by the insertion of a tubular drain at the most dependent point. Re- 
tention of the antiseptic dressing is secured best by applying a few turns 
of a plaster-of-Paris bandage. If, in spite of thorough primary disin- 
fection, asepsis is not secured, secondary disinfection is to be instituted 
at once. This requires that the superficial sutures are removed. De- 
tached bone is not to be re-implanted a second time, for fear of renewed 
infection. The whole surface is now disinfected by filling every sinus 
and depression with peroxide of hydrogen After effervescence has 
ceased the fluid is washed away by irrigation with the ordinary anti- 
septic solutions. The peroxide of hydrogen will reach parts of the 
infected surface inaccessible to other antiseptic solutions. If an}'- 
evidences, local or general, point to the existence of a beginning inflam- 
mation of the dura mater and the subjacent membranes, the deepest 
portions of the wound are subjected to thorough disinfection and tubular 
subdural drainage is established. If secondary disinfection prove un- 
successful the antiseptic dressing is to be removed and the moist anti- 
septic compress substituted, which is removed from time to time, when 
the deeper portions of the wound are cleansed by irrigation with an 
antiseptic solution. 

An external suppurative pachymeningitis is treated in the same way 



296 PRINCIPLES OF SURGERY. 

as an infected compound fracture of the skull. If it follow a com- 
pound fracture, loose, detached bones are removed, and the whole sup- 
purating surface is disinfected; after which, tubular drainage is estab- 
lished. If it follow a fissured fracture, a sufficiently large opening is 
made in the skull, to permit of free disinfection, and the accumulation 
of pus is prevented by the insertion of a tubular drain. Suppuration 
between the dura mater and the cranial vault in an intact skull is treated 
by making one or more openings in the skull for disinfection and drain- 
age. A subdural abscess without fracture of the skull is to be accu- 
rately located by a S3'stematic and accurate study of the clinical history 
of the case, and by reference to the etiology of the suppurative process, 
and the information thus obtained can usually be corroborated by focal 
symptoms which point to the exact location of the disease. The skull 
is opened with the chisel over the point where the abscess is suspected. 
If the dura bulge into the opening, is tense, and the pulsations of the 
brain cannot be felt, the surgeon may be almost sure that a subdural 
abscess is present, and confirms his suspicion by an exploratory punc- 
ture. If pus is found, the dura mater is incised, the cavity washed out 
with an antiseptic solution, and a tubular drain is inserted. A daily 
change of the dressing and washing out of the cavity with antiseptic 
solution are necessary until suppuration has nearly ceased ; then the 
dressing is removed less frequently, and the drain is shortened as the 
cavity diminishes in size. If at the point where the abscess was local- 
ized the dura present no indications of subdural, intracranial pressure, 
but the surgeon feels sure otherwise of his diagnosis, it is justifiable to 
make a number of small exploratory punctures until he succeeds in 
locating the suppurating focus. If the abscess-cavity is large, and the 
first opening has been made at a point unfavorable to efficient drainage, 
it is advisable to imitate the example of Macewen, to make a counter- 
opening in the skull and dura at the most dependent point, and to main- 
tain through drainage until suppuration ceases. A localized suppura- 
tive pachymeningitis, recognized in time, and located with sufficient 
accuracy to admit of radical treatment by operative measures, is an 
affection which the modern surgeon treats with every assurance of 
success. 

(b) Suppurative Leptomeningitis. — Inflammation of the arachnoid, 
without implication of the pia mater and surface of the brain, never 
occurs, and on this account we no longer speak of inflammation of any 
of these structures as separate lesions, but substitute the term lepto- 
meningitis, by which is meant inflammation of the two inner envelopes 
of the brain, combined witli cortical encephalitis. The surface of the 
brain is supplied in part with blood-vessels from the pia mater, and this 



ENDOCRANIAL SUPPURATION. 297 

intimate vascular connection establishes an equally intimate pathological 
relationship between these two structures. A septic leptomeningitis is 
a diffuse inflammation of the arachnoid, pia mater, and cortex of the 
brain, caused b}~ infection with pus-microbes, and which, in the absence 
of all tendencies to localization, proves fatal before well-marked suppu- 
ration has occurred. Etiologically and pathologically it resembles 
diffuse septic peritonitis. Examination of the contents of the skull 
reveals great vascularity, more or less serous transudation, and softening 
of the gray matter of the brain. Microscopical examination shows 
only a moderate emigration of the colorless corpuscles and the minute 
changes in the capillary vessels, which are characteristic of acute septic 
inflammation. Suppurative leptomeningitis is characterized by the 
presence of pus between and upon the membranes and upon the surface 
of the brain. Septic leptomeningitis always terminates in suppuration, 
if the life of the patient is sufficiently prolonged for emigration of leuco- 
cytes and their transformation into pus-corpuscles to occur. Septic 
leptomeningitis sometimes appears within a few hours after a perforating 
wound of the skull. Bergmann relates the case of a child where a 
convex meningitis could be diagnosticated four hours after an injury 
of the skull. Konig reports a case that came under his observation 
where well-marked symptoms of leptomeningitis followed ten hours after 
perforation of the skull with the point of a sword. The wound was 
examined outside of the hospital with instruments that had not been dis- 
infected. Ten hours after the injury the patient commenced vomiting, 
and had a temperature of 39° C. The following day, wild delirium, 
strabismus divergens, and a temperature of 40° C. The second day, 
coma, rapid pulse, and death. The necropsy revealed diffuse septic 
leptomeningitis. The inflammatory product is found most abundant in 
the subarachnoid space. The effusion in this space is sometimes clear, 
raising the arachnoid ; it contains, also, fibrin in flakes and membranes, 
or it presents the consistence and color of pus. Pus first appears along 
the course of blood-vessels in the pia in the shape of yellow streaks, 
which, when they become confluent, tend to considerable inflammatory 
thickening of the membrane. Pus may also appear in the ventricles by 
way of communication with the subarachnoideal spaces. On account of 
the absence of connective-tissue spaces, the inflammation of the surface 
of the brain remains superficial. If pus form here, it appears as small 
abscesses, which later may become confluent, causing superficial destruc- 
tion of the brain-substance. If the surface of the brain is the seat of a 
contusion, suppurative encephalitis is more diffuse, and may lead to a 
diffuse acute abscess underneath the infected envelopes. 

Besides wounds communicating with the atmosphere through which 



298 PRINCIPLES OF SURGERY. 

infection takes place, suppurative leptomeningitis, like pachymeningitis, 
can be caused by peripheral suppurative lesions, as phlegmonous inflam- 
mation of the soft tissues covering the skull, suppurative osteomyelitis 
of the cranial bones, and suppurative inflammation of the middle ear. 
In fractures at the base of the skull, infection frequently occurs through 
a ruptured tympanum, or through a wound of the soft parts in the naso- 
pharynx communicating directly with the meninges. 

Symptoms and Diagnosis. — The surgeon should be versed in the 
symptomatology of suppurative leptomeningitis, rather for the purpose 
of knowing when not to interfere, by operative procedure, in cases of 
endocranial suppurative lesions, than to risk his reputation in a fruitless 
attempt in operating for an incurable disease. Diffuse septic and suppu- 
rative leptomeningitis are fatal diseases, and the surgical treatments will 
in all probability always remain of a purely prophylactic character. 
The symptoms of leptomeningitis are always those of cortical encepha- 
litis, from which it cannot be distinguished during life. The disease is 
often initiated by a chill, like phlegmonous inflammation in other locali- 
ties, followed by high fever and other symptoms of septic intoxication. 
In other cases the chill is absent and the fever develops more insidiously. 
The rise of temperature, which is usually abrupt, — the thermometer after 
a few hours shows an increase to 39° or 40° C, and as a rule presents 
but slight variations, — is caused by the absorption of septic material 
from the infected and inflamed tissues. The intra-cranial pressure and 
fever give rise at once to symptoms which indicate the presence of cere- 
bral irritation. Headache, morbid sensitiveness to external impressions, 
sleeplessness, restlessness, and ps}^chical perturbation are some of the 
most constant and conspicuous early symptoms. If the patient fall 
into a short nap he starts up suddenly and behaves like a maniac. The 
pupils are usually contracted at first, but dilate as other symptoms of 
compression appear. Often they are unequal in size and respond only 
sluggishly to light. Localized general convulsions frequently attend 
the stage of irritation. Vomiting and constipation are among the early 
symptoms. Paralysis of definite muscular groups, according to Berg- 
mann, indicates extension of the disease to the region of motor centres. 
The face is suffused, the conjunctivae injected, and the pulsation? of the 
carotid arteries increased. The pulse, at first increased in frequency, 
bounding and firm, becomes slower as cerebral compression advances. 
If, after its frequency has been reduced to 40 or 50 beats per minute, it 
again becomes rapid, it is a sure indication of approaching death. 

If the disease develop in the course of a perforating wound of the 
skull, the increased intra-cranial pressure is manifested by bulging of 
the dura mater into the wound, or if the envelopes of the brain have 



ENDOCRANIAL SUPFURATION. 299 

been lacerated, by hernia of the brain. The prolapsed portion of the 
brain often sloughs, when putrefaction of the dead tissue occurs as an 
unavoidable result, and death from sepsis is hastened by such an occur- 
rence. Bergman n has recently called the attention of the profession to 
the fact that leptomeningitis, affecting the convex surface of the brain, 
leads at once to paralysis of one extremity, or hemiplegia, by the exten- 
sion of the disease to motor centres. Indications pointing to localized 
symptoms of central irritation can be explained by the same theory. 
Leptomeningitis at the base of the brain is not attended by any definite 
localized focal symptoms, and the retraction of the head takes place in 
consequence of the extension of the inflammation to the meninges of 
the spinal cord. Basilar meningitis in its advanced stage gives rise to 
a peculiar disturbance of respiration, — the Cheyne-Stokes phenomenon. 
With the appearance of compression of the brain the symptoms of cen- 
tral irritation subside and give place to the paralytic stage. The patient 
passes from a condition of listlessness gradually into a stupor, and 
final!}- into complete coma. With the appearance of monoplegia and 
hemiplegia some centres may be still in a condition of irritation, so that 
symptoms of irritation and paralysis may be manifested at the same 
time. During the paralytic stage the suffusion of the face disappears, 
the face is pallid, and the whole surface of the body covered with a 
clammy, cold perspiration ; the pupils dilate and no longer respond to 
light ; the pulse becomes small and rapid, and death is preceded by 
relaxation of all sphincter muscles. 

Treatment. — The prophylactic treatment has for its object the pre- 
vention of infection through wounds communicatino- with the contents 
of the skull. Rigid antiseptic treatment of all compound fractures of 
the skull must be carried out in the most pedantic manner. Fractures 
of the base of the skull, communicating with the atmospheric air through 
a ruptured tympanum or through a lacerated wound in the nasopharyn- 
geal region, should be treated upon the same principles as a compound 
fracture of the vault of the cranium. If the tympanum has been rup- 
tured the external meatus is thoroughly disinfected and packed loosely 
with iodoform gauze, over which a filter of salicylated cotton is applied. 
If the fracture communicate with a wound of the naso-pharyngeal 
region, disinfection is aimed at by using an antiseptic nasal douche and 
plugging the posterior nares with tampons of iodoform gauze, which are 
to be removed daily, and, after using the nasal douche, are to be replaced 
by new ones. The prophylactic treatment of leptomeningitis, caused by 
suppurating foci in the coverings of the skull, the internal ear, or in the 
cranial bones, can be carried out most successfully by early and rational 
treatment of the primary diseases. With the first appearance of the 



300 PRINCIPLES OF SURGERY. 

symptoms of leptomeningitis, the surgeon should lose no time in render- 
ing the wound or primary suppurating depot aseptic by operative 
measures, combined with most rigid antiseptic precautions, with a faint 
hope that such measures ma}^, in exceptional cases at least, lead to a 
successful issue by limiting the extension of the infection. As soon as 
the disease has become diffuse the prospects of a favorable termination 
are almost nil. It may be possible that multiple openings in the skull, 
with subarachnoid drainage and frequent antiseptie irrigations or per- 
manent irrigation, will in the future become an established and feasible 
method of treatment in such cases. From a surgical stand-point such 
heroic treatment appears the only rational course to pursue in a class of 
patients otherwise doomed to certain death. The multiple perforations 
would have a potent influence in diminishing the intra-cranial pressure, 
and drainage, combined with frequent or permanent irrigation, might, at 
least in a small percentage of cases, succeed in sterilizing the extensive 
area of infection. 

BRAIN-ABSCESS. 

The term abscess of the brain should be limited to circumscribed 
collections of pus surrounded on all sides by brain-tissue. Suppuration 
occurring between the brain and its envelopes, from a circumscribed 
suppurative leptomeningitis, is not a brain-abscess. A brain-abscess is 
the result of a circumscribed suppurative encephalitis. The acute form 
occurs when a contused portion of the brain becomes infected through 
a wound communicating with the atmospheric air, but, as this form will 
seldom, if ever, become the subject of successful operative treatment, 
our remarks will apply to abscess of the brain proper, or chronic abscess. 
A chronic circumscribed encephalitis may originate in a contused area 
of the brain, without any external wound or direct route of infection, 
from localization of pus-microbes in the locus minoris resistentise. Such 
cases have been frequently observed where, weeks and months after the 
subsidence of the symptoms resulting from the immediate effects of a 
head injury, remote symptoms pointed to a central suppurating focus in 
the brain. The occurrence of such grave remote consequences renders 
the prognosis, even after slight injuries to the skull, always more or less 
doubtful. In other instances an abscess forms around a foreign body 
that has lodged in the brain, and has remained for a long time without 
having given rise to any local or general disturbance. Infected pene- 
trating wounds of the skull may heal, and the patient apparently recover 
perfect health, when at some remote time, and in direct causal connec- 
tion with the previous infection, a chronic abscess develops, perhaps, 
some distance from the primary seat of infection. Most frequently such 
abscesses are caused by suppurative inflammation of the internal ear, 



BRAIN- ABSCESS. 301 

and suppurative osteomyelitis of the cranial bones. In size they vary 
from that of a pea to that of an entire hemisphere. They may remain 
stationary for twenty years, but the period of latency may pass into 
activity at any time. A large abscess in the white substance of a hemi- 
sphere may give rise to no functional disturbances whatever, and can 
onty be recognized by the terminal s}anptoms. In other cases the abscess 
can not only be diagnosticated during life, but its location accurately 
determined by symptoms which point to destruction of a particular 
part of the brain. 

Symptoms and Diagnosis. — The first symptoms are insidious in their 
onset, and often of a very indefinite nature. The first thing noticed is, 
frequently, a hypersensitiveness and irritable temper of the patient, 
with more or less severe headache. Early loss of memory is often 
noticed, and the patient becomes dull, sullen, unconcerned, and reckless 
in his business transactions. If the abscess involve any of the motor 
centres, or a considerable portion of fibres originating from them, mono- 
spasm or hemispasm, or monoplegia or hemiplegia follow as peripheral 
evidences of the central lesion. General convulsions, which sometimes 
occur at this stage, have less diagnostic value than localized focal symp- 
toms. Abscess of the brain seldom causes fever ; on the other hand, the 
temperature is often subnormal. A sudden rise in temperature indicates 
that the abscess has reached the surface of the brain, and that a terminal 
leptomeningitis has developed. Rupture of an abscess into one of the 
ventricles is followed by general convulsions, paralysis, and death. 
Prominence of the dura over the abscess and absence or diminution of 
cerebral pulsation are important diagnostic signs, especially in cases 
where the abscess is located near the surface of the brain. Examination 
of the exposed brain by palpation may elicit evidences of deep-seated 
fluctuation. In exceptional cases the portion of brain covering the 
abscess is firmer than normal from inflammatory infiltration (Rose). 

Gussenbauer states that in some cases the presence of the abscess 
can be ascertained by the existence of fluctuation. 

Prognosis. — An abscess in the brain is always an imminent source 
of danger to life. A considerable accumulation of pus in the brain, like 
in any other organ, is never removed by absorption. If the abscess 
remain in the active stage it gradually increases in size until it ruptures 
into one of the ventricles or reaches the surface of the brain, in either 
event resulting in complications which lead to a rapidly fatal termination. 
It may remain in a latent condition for an indefinite period of time, but 
the life of the patient is always in jeopardy, as acute exacerbations may 
come on at any time. If an abscess form after a perforating injur}' of 
the skull, and the pus finds an exit through a permanent fistulous open. 



302 PRINCIPLES OF SURGERY. 

ing, the general health may remain sufficiently good to enable the patient 
to follow his occupation. A case came recently under my observation 
where I could introduce the probe to a distance of four inches into the 
brain, and yet the general health remained unimpaired, although this 
condition had existed for years. The brain-abscess in this case devel- 
oped in connection with purulent inflammation of the middle ear. I 
have knowledge of another case, where a young man received a perfo- 
rating wound of the skull, which was followed by the formation of an 
abscess of the brain that discharged externally. The patient filled, in a 
creditable maimer, a responsible and important government position for 
thirty years, and died from another cause. 

The necropsy showed an abscess-cavity the size of an orange, located 
in the anterior right lobe of the brain, which communicated with the 
external surface through a fistulous opening in the skull. A few cases 
are reported where recovery followed the spontaneous discharge of the 
contents of the abscess through the ear or nose, but ordinarily such an 
occurrence is followed by putrefaction of the remaining contents of the 
abscess-cavity and death from sepsis. 

Treatment. — All efforts to cure an abscess of the brain by external 
applications or internal medication will be worse than useless in effect- 
ing removal of the pus by absorption. All expectant treatment is worse 
than useless. Brain-abscess must be treated on the same principles as ab- 
scess in any other organ, — by incision and drainage. The great difficulty 
in these cases is to make a sufficiently accurate diagnosis in regard to 
the exact location of the abscess. Before anything was known in refer- 
ence to the subject of cerebral localization, Dupuytren plunged a bistoury 
deeply into the brain, and was fortunate enough to hit an abscess which 
he suspected, and his patient recovered. The same bold treatment has 
been frequently followed since, but not with the same brilliant result, as, 
in the majority of cases, either no abscess existed or the incision was 
made not into, but aside of, the abscess. Localized tubercular lesions of 
the brain giving rise to focal symptoms, resembling, in this respect, 
tumors or abscesses, are of frequent occurrence, and, if they can be 
recognized, furnish a contra-indication to surgical interference. Of 300 
cases of brain-tumor, reported by Starr as occurring in persons under 19 
years of age, 152 were tubercular. Eight of the 20 cases of tumor of 
the brain reported by Osier were tubercular. Of 28 cases that came 
under the observation of Mills, T were known to be of the same nature. 
Renz cured an abscess of the brain by repeated aspirations through a 
fissure in the skull. The average surgeon, at the present time, would 
not undertake to incise a brain for abscess unless he had previously 
located the abscess by a careful study of focal symptoms, and by a 
resort to exploratory punctures. Bergmann condemns the use of the 



BRAIN-ABSCESS. 



303 



exploring-syringe for this purpose, but in the hands of those less skilled 
in cerebral localization than this eminent surgeon the exploring-needle 
will be regarded as a welcome and useful instrument of exact diagnosis. 
Cerebral Localization. — As the peripheral symptoms upon which the 
surgeon relies in locating an abscess in the brain are caused by irritation 
or destruction of the motor tracts or centres, it is absolutely necessary 
for him to become familiar with the topography of the motor centres. 
A. W. Hare gives a very practical instruction on cerebral localization in 
a paper published in the London Lancet, March 3, 1888, from which I 
quote : " In the parietal region, grouped around the fissure of Rolando, 
are the areas associated with movements of the extremities of the oppo- 
site side of the body, and, at the lower end of the fissure, those related to 
movements of the mouth 
and tongue. In the 
accompanying diagram 
the motor areas have 
been marked in their 
anatomical relations to 
the other structures of 
a normal head, dissected 




Fig. 108.— Motor Areas. 



for the purpose, show- 
ing the brain- in its natu- 
ral position. The areas 
associated with move- 
ments in neighboring 
regions of the body have 
been shaded alike in the 
figure. Tli us, the areas 
A, B, C, and D, bounding the fissure of Rolando posteriorVv, and 
5 and 6, in front of the fissure, together with 2, 3, and 4, at its 
upper end, are those in functional connection with the upper ex- 
tremity ; A, B, C, and D being concerned in the movements of the 
fingers, head, and wrist, 5 in a forward movement of the arm, 6 in pro- 
nation and supination of the forearm, and 2, 3, and 4 in co-ordinated 
movements of the whole upper extremit}^. The areas 7, 8, 9, 10, and 11, 
indicated as having a common region of motor representation, are re- 
lated to movements of the tongue and of the muscles around the mouth. 
Area 1 represents in part movements of the lower extremity. In the 
same way areas of representation of general and of special sensation are 
located Iry Ferrier around the horizontal limb of the fissure of Sylvius. 
It must not be overlooked that this mapping out of areas has an absolute 
exactitude only in the case of the species of ape upon which the experi- 
ments were performed. Its bearing in the human subject is one of great 



304 PRINCIPLES OF SURGERY. 

relative importance, but it must not be looked upon as a final statement 
of fact, in the case of man, until each area can be shown to be correctly 
placed, as it is by the accumulation of a sufficient number of clinical and 
of post-mortem observations directly confirming the method employed. 

" In the study of cranio-cerebral topography the surgeon has to rely 
on four primary landmarks in establishing a S3<stem of measurements. 
These are the glabella, or root of the nose, which bears a definite relation 
to the anterior limit of the cranial cavity, and the occipital protuberance, 
or inion, which bears a similar relation to its posterior end, correspond- 
ing to the junction of the falx with the tentorium. The whole mass of 
the cerebrum is disposed between these two points, and the} T bear definite 
relations to its cortical matter, uninfluenced by the structure and contour 
of the bones forming the vault. The third constant landmark is the 
external angular process of the frontal bone, which bears a relation to 
the lateral expansion of the frontal lobes, similar to that borne by the 
two prominences already mentioned, to the anterior and posterior ex- 
tremities of the cerebrum. It has also a uniform relation to the fissure 
of Sjdvius. Lastly, the parietal eminence is of value, since it marks the 
greatest lateral expansion of the substance of the hemisphere, and, as 
Turner has shown, bears a special relation to the submarginal convolu- 
tion. To find the upper end of the fissure of Rolando by the use of 
these data, the surface measurement in the middle line of the head should 
be taken over the scalp from the glabella to the occipital protuberance. 
In ordinary adult heads this will vary from 11 to 13 inches; measured 
along this line from before backward, the distance from the glabella to 
the top of the fissure will be 55. 7 per cent, of the total distance from the 
glabella to the occipital protuberance. The following scale shows the 
distance from the glabella to the top of the fissure in all ordinary 
heads : — 



When the distance from the glabella to the 


The distance from the glabella to the upper 


occipital protuberance is 


end of the fissure of Rolando is 


11 inches, 


6^ inches. 


ll£ " 


6f " 


12 " 


6f " 


m " 


7 " 



13 " 7£ " 

" To find the top of the Rolandic fissure, Thane halves the distance 
from the glabella to the occipital protuberance, and, having thus de- 
fined the middle point of the vertex, takes a point half an inch behind it as 
the location of the upper end of the fissure. Having thus ascertained 
the upper end of the fissure, it is desirable to determine its length 
and direction. The scalp measurement corresponding to its length is 



BRAIN-ABSCESS. 



305 



3J inches. It runs from above downward and forward, its axis making 
an angle of 67 degrees with the middle line. 

" Wilson's cyrtometer is an exceedingly useful aid in locating the 
fissure of Rolando. It consists of three strips of flexible metal and a tape 
for securing it in situ. The method of its application is illustrated by 
Fig. 110. 

" The broadest, transverse strip passes coronally around the forehead, 
corresponding with the glabella and external angular process ; the 
narrower, longitudinal strip passes backward from the glabella in the 
middle line to the occiput. This strip is marked with two scales of 

n R 




Fig. 109.— Wilson's Cyrtometer. 



--> Fig. 110.— Wilson's Cyrtom- 
_jy eter Applied. 

G, glabella ; E A P, external angular 
process ; R, fissure of Rolando, its posi- 
tion and direction marked by the lateral 
strip of metal. 



letters, — capitals in its posterior fourth, and small letters about the 
middle of the strip. These two scales bear a relation to one another, 
calculated to aid in the application of the instrument to an ordinary 
head. Measured from the glabella backward, the distance to any 
given small letter is 55.T per cent, of the distance from the glabella to 
the corresponding capital letter; thus, when any capital letter will co- 
incide with the top of the fissure, a third narrow, reversible strip strikes 
on the longitudinal strip of metal, marking an angle of 67 degrees, opening 
forward and marked at 3| inches from its attached end, thus giving the 
length and direction of the fissure on the surface of the head. To de- 
termine the exact location and direction of the fissure, a line is drawn 

20 



306 



PRINCIPLES OF SURGERY. 



from the external angular process of the frontal hone backward to the 
occipital protuberance, taking the shortest route between these points. 
Such a line drops a little toward the external auditory meatus, avoiding 
the greater convexit} T of the skull, which lies in the course of a hori- 
zontal line between the boii3 r prominences. It usually passes about J 
inch above the meatus, and thus closely corresponds to the floor of the 
middle fossa, and behind runs parallel to and nearly in the same course 
with the attachment of the tentorium and the posterior half of the 
lateral sinus. A measurement of 1^ inches along this line, backward 



E.R. 



O.R 




Fig. 111.— Head, Skull, and Cerebral Fissures. {Adapted from Marshall.) 

O P. occipital protuberance: E A P, external angular process: S F. Sylvian fissure: A. its ascending 
limb : F R. fissure of Rolando : P E, parietal eminence ; M M A, middle meningeal artery • T S, tip of 
temporo-sphenoidal lobe ; B, Broca's convolution. 

from the external angular process, marks the lower end of the fissure 
of Sylvius. From this point a straight line drawn to the centre 
of the parietal eminence accurately marks the course of the posterior 
limb of the fissure. The main line of the fissure follows the line of the 
squamo -parietal suture to its highest point, whence it continues its course 
to the parietal eminence. The middle meningeal artery, after grooving 
the inner surface of the great wing of the sphenoid, passes on to the ante- 
rior angle of the parietal bone, and is distributed to the dura mater lining 
the anterior and superior half of the bone. If the surgeon desire to ex- 
pose the tip of the temporo-sphenoidal lobe, he should open the skull 



BRAIN-ABSCESS. 307 

behind the upper extremity of the- great wing of the sphenoid ; if to expose 
Broca's convolution, immediately in front of the same bony peninsula. 
The sites of the two operations are shown in Fig. 111." 

Opening of the Skull. — The operative treatment of abscess of the 
brain presupposes an accurate diagnosis by means of cerebral localiza- 
tion and a careful study of the clinical and etiological aspects of the 
case. If symptoms of abscess of the brain arise, after a compound frac- 
ture of the skull, before the continuity of the skull lias been restored, 
exploration can be done with a fine needle through a fissure, or at 
some point where fragments have been removed ; and, if pus is found, a 
closed haemostatic forceps can be pushed along the side of the needle 
into the abscess, and the track enlarged by separating the blades before 
withdrawing the instruments. Into this track a drainage-tube is intro- 
duced, the abscess-cavity gently irrigated, and the wound disinfected and 
dressed antiseptically ; or, a small quantity of peroxide of hydrogen 
can be injected into the abscess-cavity through the drainage-tube, which 
will not only force out the contents, but will also sterilize the walls of 
the abscess more thoroughly than any other antiseptic. If an abscess 
develop in the brain in an intact skull, or after the fracture has healed, 
the skull must be opened at a point immediately over the abscess. By 
means of the measurements given, or by the use of Wilson's cyrtometer, 
the motor centre or centres affected by the abscess are marked upon the 
shaved and disinfected scalp before the skull is exposed ; and the exact 
location of the abscess is also marked on the skull by making a puncture 
through the scalp with a small perforator, so that the location can be 
recognized after the soft parts have been reflected. The bone is laid 
bare at this point by Horsley's flap, which is made by ahorse-shoe-shaped 
incision, the convexity of which is directed upward. The flap, with the 
periosteum attached, is turned downward. After all haemorrhage has 
been arrested the skull is opened, either by using a large trephine or, 
what is better, with a chisel ; the button of bone or bone-chips are trans- 
ferred into a warm antiseptic solution, where they are kept until needed 
for re-implantation, should this be deemed necessaiy or advisable. If the 
dura mater is tense and bulge into the opening, and cerebral pulsations 
are feeble and entirely wanting, the indications are that the skull has 
been opened near or directly over the abscess. The opening need not be 
larger than an inch in diameter. 

Methodical Exploration of the Brain. — Experiments and clinical 
experience have shown that the brain can be explored in different direc- 
tions with a fine, hollow, aseptic needle without any immediate or remote 
bad effects. The brain should never be incised for abscess until the 
abscess has been located by methodical exploration. Aii ordinary 



308 PRINCIPLES OF SURGERY. 

exploring-syringe with a delicate needle about 4 inches in length 
should be used for this purpose. The needle is pushed into the brain in 
the direction in which the abscess is suspected, and to the necessary 
depth, when aspiration is made and the result carefully noted. If no 
pus is found the needle is withdrawn or pushed forward in the same 
direction, and aspiration made at different points in its track ; and, if no 
pus is found in that direction, it is withdrawn and pushed in another 
direction, aud the same manoeuvres repeated. In this manner a large 
territory can be explored and even very small abscesses located. When 
the abscess has been located by this method of exploration, the needle is 
used as a guide for a small pair of haemostatic forceps, which is pushed 
forward along its side until the abscess has been reached, when it is 
unlocked, the blades slightly separated, and as the instrument is with- 
drawn the track is sufficient^ enlarged to permit the insertion of a 
rubber drain the size of an ordinary lead-pencil. The needle is only 
removed after the drain is in situ. Fenger, of Chicago, has written an 
exceedingly valuable paper on exploration of the brain, in the diagnosis 
and treatment of abscess of the brain, in which he has furnished abundant 
proof both of the harmlessness and utility of this procedure. 

After the abscess has been opened and drained, it is advisable to 
wash it out gently with some non-irritating and yet effective antiseptic 
solution, either with half of a 1-per-cent. solution of acetate of aluminum 
or a 2 per-cent. solution of boric acid. 

As the abscess-walls are never firm, every precaution must be 
taken to prevent overdistention, but gentle irrigation is continued until 
the fluid returns clear. If the skull has been opened by removing a 
disk of bone by trephining, an opening in this must be made at its lower 
margin, which will permit bringing the drainage-tube out to the external 
surface after implantation. If bone-chips are re-implanted, a space 
for the drain must be left in the most dependent portion of the opening. 
The drainage-tube is brought out at one of the lower angles of the wound 
or through a button-hole in the flap. The flap is secured in its position 
by a requisite number of sutures. Daily changes of dressing is required 
until suppuration diminishes, when the drain is shortened from time to 
time and the dressing changed less frequenthy. The drainage-tube is not 
to be removed until the abscess-cavity is closed, as otherwise a relapse 
would be liable to occur which would require a repetition of the first 
operation. The most unsatisfactory aspect of the surgical treatment of 
abscess of the brain is the fact that in some instances multiple abscesses 
are present, — an occurrence which is beyond the limits of the present 
means of diagnosis. In such cases the surgeon may cure one abscess, 
but the patient succumbs from the effect of those that have not been 



EMPYEMA. 309 

discovered. The appearance of a hernia cerebri, Sifter the evacuation 
and drainage of an abscess of the brain, is a condition which points to 
the existence of an additional abscess or abscesses. Should such a 
condition appear during the after-treatment of an abscess of the brain, 
treated by evacuation and drainage, it would furnish a strong temptation 
to resort to another methodical exploration with a view of subjecting 
additional abscesses to the same radical treatment. Should the first 
opening into an abscess of the brain not be suitable for effective drainage, 
it would be well to follow the example of Macewen and open the skull 
at a lower point, tunnel the intervening portion of the brain, between 
this opening and the abscess cavity, with haemostatic forceps, and thus 
establish an additional and more efficient route for drainage. In the 
surgical treatment of abscess following suppurative inflammation of the 
middle ear, it is well to remember that in these cases the abscess is 
usually located in the vicinity of the petrous portion of the temporal 
bone, and that in exploring the brain the needle should be inserted in 
this direction. 

EMPYEMA. 

Empyema is a collection of pus in the pleural cavity. It is always 
the result of a suppurative pleuritis. 

Bacteriological Studies. — : A penetrating wound of the pleural cavity 
is more frequently followed by infection with pus-microbes and suppura- 
tive pleuritis than perforation of one of the bronchial tubes, as in the 
latter accident the atmospheric air entering the pleural cavity has under- 
gone a process of filtration during its passage through the respiratory 
tract. Suppurative pleuritis, occurring without direct infection through 
a perforation in the thoracic wall or one of the bronchial tubes, is always 
caused by localization of pus-microbes within or upon the serous mem- 
brane lining the pleural cavity. Localization of pus-microbes occurs in 
the pleura or pleural cavitj^, either as a primary or secondaiy infection. 
Frankel made a bacteriological study of 12 cases of empyema. In 
3 cases, in which no special cause could be traced, the pus contained 
exclusively the streptococcus pyogenes. In 3 cases the pus contained 
only pneumococci. Other authors have found in such cases also other 
pus-microbes. Frankel believes that when this is the case they have 
localized in consequence of a secondary invasion. The presence of 
streptococci in the pus from a suppurating pleural cavity presents noth- 
ing characteristic, as the microbe is also found in cases in which the 
empyema is secondary to pneumonia and tuberculosis. On the other 
hand, he assigns to the pneumococcus, in pus taken from a pleural cavity, 
a diagnostic significance, as it proves, beyond all doubt, that the suppu- 
rative pleuritis occurred in the course of a pneumonia as a secondary 



310 PRINCIPLES OF SURGERY. 

affection ; consequently, its presence in the pus is positive proof that a 
pneumonia exists or has existed, even if the clinical and physical symp- 
toms were not sufficiently clear to indicate its existence. In 4 cases 
the empyema had a tubercular origin, in 2 of which pneumothorax 
was present at the same time. The presence of the bacillus of tubercu' 
losis in the pus is not easily demonstrated, but the absence of this 
microbe is no sign that the disease is not tubercular, as inoculations 
with pus in animals almost constantly produce typical tuberculosis. In 
the pus of tubercular pyo-pneumothorax, if microorganisms are present, 
the bacillus of tuberculosis can be found, and the pus shows no tendency 
to undergo putrefactive changes, in contradistinction to empyema occur- 
ring in non-tuberculous subjects, in whom spontaneous discharge through 
the bronchial tubes takes place. Senator maintains that putrefaction is 
prevented by the parenchyma of the lungs acting as a filter, preventing 
ingress of bacteria with the inspired air, and by the presence of a large 
amount of carbonic-acid gas in the air of t'he cavity, as it is well known 
that microbes do not thrive so well in such an atmosphere as in ordinary 
air. Ehrlich has made an interesting bacteriological examination of 
the pus in 19 cases of empyema ; in only 7 of these could the bacillus 
of tuberculosis be found ; in the remaining 12 this microbe could not 
be detected, and upon this negative ground the existence of tuberculosis 
was excluded. Further observation in these cases after operation cor- 
roborated the diagnosis. He asserts, therefore, that, in the purulent 
pleuritic exudation in tubercular patients in empyema and pyo-pneumo- 
thorax, the presence of the specific microbic cause can alwaj^s be demon- 
strated. This author places the greatest importance on a bacteriological 
examination of the pus as a means of differential diagnosis between sup- 
purative and tubercular empyema. A serous effusion is not infrequently 
transformed into an empyema by a change of the predominant bacterio- 
logical cause. In a number of cases I found it necessary to aspirate the 
chest for the removal of a copious effusion. The fluid removed at the 
first aspiration was clear serum ; the second aspiration removed a slight, 
turbid fluid, and the third aspiration yielded a distinctly sero-purulent 
fluid ; while the fourth aspiration revealed a well-marked empyema. In 
all of these cases the subsequent history and termination showed that 
tuberculosis was the primary cause of the effusion. Infection of the 
tnbercular foci with pus-microbes, and the entrance of these into a cavity 
already changed by disease, altered the type of the inflammation and the 
character of the effusion. Putrefaction of the products of suppurative 
pleuritis occurs occasionally without the presence of a direct communi- 
cation of the pleural cavity with the atmospheric air. I have seen 2 
cases of this kind, and both recovered after radical operation. In such 



EMPYEMA. 311 

instances we must take it for granted that saproplr^tic bacilli find their 
way into the pleural cavity through the respiratory passages and the 
parenchyma of the lungs, and select the products of coagulation necrosis 
for their nutrient medium. The pus in such cases is exceedingly fetid, 
thin, and usually contains large shreds of fibrin. The ptomaines of the 
putrefactive bacteria increase the fever and other symptoms of septic 
intoxication. 

Diagnosis. — The presence of a considerable quantity of fluid gives 
rise to well-marked clinical and physical sj^mptoms. Aside from the 
ordinary s}^mptoms which point to a suppurative inflammation in other 
localities, such as chill, fever, pain, loss of appetite, the patient complains 
of difficulty of breathing, especially on lying down, and sometimes, but 
not always, of. a short, hacking cough. On physical examination it 
becomes apparent that a part or nearly the entire pleural cavity is occu- 
pied by a fluid. Dullness on percussion and absence of respiratory and 
voice sounds over the area occupied by the fluid, and displacement of 
adjacent organs by the intra-thoracic pressure, are signs which cannot 
be well simulated by anything else than accumulation of fluid in the 
pleural cavity. Bulging of intercostal spaces, as a rule, is more marked 
in empyema than hydrothorax. In ercqryema the subcutaneous tissues 
on the affected side are often slightly (Edematous and the superficial 
veins are sometimes enlarged. In empyema of the right pleural cavity 
the liver is pushed in a downward direction, while the heart is displaced 
toward the left side. In empyema of the left side the apex-beat of the 
heart can quite frequently be felt on the right side of the sternum. A 
temperature of 100° to 101° F. in the morning and 101° to 103° F. 
in the evening, continued for several weeks, speaks strongty in favor 
of emp3 r ema. A positive diagnosis alwa}^s rests on demonstrating the 
presence of pus in the pleural cavity, which can be done, without danger 
and without pain worth mentioning, by an exploratory puncture with an 
ordinary hypodermic needle. In puncturing the chest for exploratory 
or therapeutic purposes, it should be borne in mind that the needle 
should be inserted in a direction which corresponds to the centre of the 
intercostal space, consequently in an oblique direction from below 
upward. If no contra-indications present themselves, the exploratory 
puncture should be made at the place where, later, the radical operation 
will be performed ; that is, in the axillary line, between the sixth and 
seventh or seventh and eighth ribs. If the needle is perfectly aseptic 
no harm will result, even should the lung or liver be punctured. 

Prognosis. — Simple, uncomplicated suppurative pleuritis offers a 
favorable prognosis if subjected to early radical treatment. The prog- 
nosis is more favorable in children than in adults, and in recent than in 



312 PRINCIPLES OF SURGERY. 

old cases. In long-standing empyema the lung becomes atelectatic from 
compression, and its full expansion is also prohibited by numerous firm 
adhesions. In children, partial expansion of the lung is compensated 
for hy retraction of the yielding chest-wall, enabling the pleural cavity 
to close ; while, in the adult, incomplete expansion of the lung results 
in a physical condition which renders definitive healing a difficult, if not 
even an impossible, occurrence. Pulmonaiy tuberculosis complicated 
by empyema constitutes a contra-indication to radical operation, as the 
patient is already affected by a disease which almost necessarily leads 
to a fatal issue, and a radical operation would only hasten this termi- 
nation. 

A fistulous communication between a bronchial tube and the pleural 
cavity, resulting from a rupture of an empyema in this direction, in 
exceptional cases, leads to a spontaneous cure, but more frequently 
becomes a cause of retardation of recovery after an operation. 

Treatment. — An empyema is nothing more nor less than an abscess 
in the pleural cavit} 7 , and should be treated as such. There can be no 
doubt that in exceptional instances a cure has been effected by aspira- 
tion. This method of treatment promises more in children than in 
adults, and it is also in the former that the radical operation has yielded 
the best results ; hence it is not advisable to have recourse to an uncer- 
tain procedure if a radical operation accomplish the same result with 
greater certainty, more speedily, and with no greater immediate and 
remote risks to life. It is a good plan in every case to combine aspira- 
tion with exploration, for the purpose of improving the conditions for a 
radical operation. By aspiration we demonstrate the presence of pus in 
the pleural cavit} 7 , and, by removing the fluid completely or in part, we 
aid the expansion of the lung, which, by the time the radical operation 
is performed, has become adherent lower down. Aspiration is to be 
followed, in the course of two or three daj's, by a radical operation. Ity 
a radical operation we understand incision of the pleural cavity and 
draining the same. The operation for emp} T ema by incision and drain- 
age must alwa}^s be done under the strictest antiseptic precautions, as 
any mistake or negligence in this regard is exceedingly liable to be 
followed by infection with putrefactive bacteria, — an occurrence which 
would greatly increase the danger from sepsis. Nothing but perfectly 
aseptic material must be used, and the whole chest of the patient and 
the hands of the operator must be thoroughly disinfected by washing 
with hot water and potash-soap, and disinfecting with a l-to-1000 solu- 
tion of sublimate, and finally with alcohol. The instruments must be 
boiled for at least ten minutes. 

(a) Incisions. — If an emp3 T ema is perforating the chest-wall and 



EMPYEMA. 313 

appears as a subcutaneous abscess, the incision is made through the 
centre of the abscess and parallel to the ribs. If no such indication is 
present, the incision should be made over the centre of the sixth rib and 
parallel to it on the right side, and over the seventh on the left, at a 
point half-way between the nipple and the axillary line. It must be 
about 4 inches in length and extend down to the bone. 

(b) Resection of Rib. — The soft parts, with the periosteum, are 
reflected with an elevator, which is then passed between the periosteum 
and rib, posteriorly, from below upward, and the periosteum separated 
to the extent of 1\ inches. If the elevator is kept in close con- 
tact with the bone, there is no danger of injuring the intercostal vessels 
or nerves, nor of opening the pleural cavity prematurely. With the 
elevator the rib is raised, and a section \\ inches in length is removed 
with a pair of heavy bone-forceps. After the removal of the bone, all 
haemorrhage is carefully checked. If the pleura feel tense and bulge 
into the wound, there is no necessity of making another exploratory 
puncture. If this is not the case, as a matter of precaution, another 
puncture can be made, at this stage of the operation, to satisfy the sur- 
geon of the presence of pus underneath. The incision into the pleura 
is then made with a bistoury, in the centre of the periosteal gutter, 
through this membrane and the pleura, into the cavity of the chest. This 
incision must be large enough to allow the insertion of drainage-tubes 
the size of the little finger.' The deep incision in the soft parts can be 
readily dilated to the requisite extent by the insertion of a finger, 
which may also be used in interrupting the flow. 

(c) Evacuation of Pus and Removal of Membranes. — A great deal of 
information is gained, as soon as the incision into the chest has been 
made, in reference to the expansibility of the lung. If this has not 
been much impaired, the pus will continue to escape with much force, 
especially during inspiration. Rapid evacuation is attended by some 
danger, from overdistention of the heart and vessels in the lung, and 
must be guarded against by interrupting the flow, from time to time, 
by inserting the index finger into the opening. If the lung expand 
promptly, its lower margin can often be seen through the opening 
toward the end of evacuation. The more the lung expands, the less 
the amount of air rushing through the opening into the chest. In order 
to prevent syncope upon the sudden diminution of intra-thoracic 
pressure, during evacuation of the pus, I have been in the habit 
of administering, before the anaesthetic is given, t ±q grain of 
atropia with J grain of morphia, hypodermaticalty, with an alco- 
holic stimulant, by the stomach or rectum. In cases of emp3 r ema 
with a bronchial fistula, and in cases where respiration was so much 



314 PRINCIPLES OF SURGERY. 

embarrassed that I deemed the administration of an anaesthetic hazard- 
ous, I have repeatedly made the radical operation without narcosis, and 
the remedies which have just been mentioned answered an excellent 
purpose in diminishing the pain. If, as is so often the case, the pleura is 
lined with thick, partially-detached membranes, these should be removed 
with a dull curette, as they are invariably infected with pus-microbes, 
and their presence in the pleural cavity would prolong the infection and 
retard recovery. 

(d) Irrigation. — Irrigation of the pleural cavity immediately after 
the operation is positively contra-indicated if a bronchial fistula is pres- 
ent, and it is superfluous if no putrefaction is present. In fetid empyema 
the cavity is washed out with warm, salicylated water until the fluid 
returns clear. This is followed by an irrigation, for a very short time, 
with a l-to-1000 solution of corrosive sublimate. None of this solution 
should be allowed to remain in the pleural cavity. 

(e) Drainage. — Rib resection should always be done in operations 
for empyema, as the space thus created offers ample room for the inser- 
tion of a large drain. I have frequently seen, after incision and drainage 
through intercostal space, circumscribed destructive processes of the 
margins of both ribs from pressure caused by the drainage-tube. Such 
pressure is not only a source of pain, but interferes also with free drain- 
age. Resection of such a small portion of a rib does not add to the 
gravity of the operation, and is of the greatest utility in the subsequent 
management of the case. The best drain is a fenestrated rubber tube 
the size of the little finger, or two rubber tubes, somewhat smaller, 
stitched together. The tube should be from 4 to 6 inches in length, 
and always secured externally with a large safety-pin, to prevent its 
slipping into the pleural cavity. Non-observance of this little precaution 
has resulted in a great deal of trouble from drains becoming lost in the 
pleural cavity. The necessity of making a counter-opening and of 
establishing through drainage does not arise often, but, when such a pro- 
cedure becomes necessary, it can readily be done with a large Pean 
forceps, which can be introduced into the anterior opening, and, by 
pushing it through the intercostal space behind, which has been selected 
for the counter-opening, an incision is made down upon its point, after 
which the opening is dilated and a long drain drawn through both 
openings. After completion of the operation a large antiseptic dressing 
is applied. 

After-Treatment. — Daily change of the dressing and antiseptic irri- 
gation will be necessary in fetid empyema, if the primary disinfection 
has not proved successful, in rendering the cavity free from putrefactive 
bacteria and necrosed material. In ordinary cases the dressing is not 



EMPYEMA. 315 

removed until it becomes saturated with the discharges, or if the tem- 
perature indicate the retention of septic material. Should, at any time, 
evidences of putrefaction or sepsis develop, antiseptic irrigations are 
positively indicated. A saturated solution of acetate of aluminum, an 
aqueous solution of tincture of iodine, a 2-per-cent. solution of boracic 
acid, or salicylated water can be used for this purpose ; always using the 
solutions at blood-heat, as the irrigation of the pleural cavity with a cold 
or cool solution has in a number of cases resulted in death from shock. 
In one of my cases the wife of the patient irrigated the pleural cavity 
with what she afterward called a cool solution, and the patient died sud- 
denly with s}^mptoms of collapse. In another case, a patient 5 years 
of age, I made the irrigation myself, using only water, the temperature, 
as I afterward ascertained, being below blood-heat, when the patient 
suddenly became pulseless and the respirations ceased. Artificial respi- 
ration had to be continued for a considerable length of time, when, to my 
great relief, the child commenced to breath spontaneously and the pulse 
and color of the face returned. This experience warned me to exercise 
care in using solutions of a proper temperature in irrigations of the 
pleural cavit} r . The final expansion of the lung and obliteration of the 
pleural cavity are accomplished by the granulating process. The drain 
should be disinfected every time, and before it is re-inserted it should be 
dusted with iodoform. 

(a) Multiple Resection of Ribs. — In cases of empyema where, after a 
radical operation, only partial expansion of the lung takes place, and the 
pleural cavity cannot close on account of the unyielding nature of the 
chest-wall, Estlander's operation of multiple resection of ribs is indicated. 
The operation consists in removing sections of 3 to 6 centimetres in 
length of all the ribs over the abscess-cavity, for the purpose of allowing 
the chest-wall to sink in, and thus remove the mechanical obstacle to 
closure of the pleural cavity. Through one incision over an intercostal 
space 2 adjacent ribs can be removed. If more than 2 ribs have to 
be resected, I prefer to make a single incision in the direction of the 
axillary line, through which, after dissecting back the superficial soft 
parts for 1 or 2 inches on each side of the incision, 6 or 8 ribs can 
be readily resected. Estlander's operation is absolutely valueless in 
cases where the lung is almost completely collapsed, as in such instances 
even the most extensive resection of ribs would fail in correcting the 
mechanical difficulty in the wa}^ of a definitive healing of the pleural 
abscess. The operation is also contra-indicated where further expansion 
of the lung depends on incurable lesions of this organ. 

(b) Thoracoplastic Operation. — In obstinate cases of empyema, 
where even Estlander's operation fails in effecting a cure, and where the 



316 PRINCIPLES, OF SURGERY. 

difficulties in the way are of a purety mechanical nature, Schede has 
recently described a procedure which, in realit} 7 , is a plastic operation. 
He not only makes resection of several ribs, but resects the entire tho- 
racic wall over the cavit}^, with the exclusion of the skin. He makes a 
skin-flap with its base directed upward, corresponding in size to the cavity 
underneath, and then removes all of the ribs in the region to the same 
extent, and finally resects the remaining portion of the chest-wall. This 
operation exposes one side of the cavity completely, and the opposite 
wall is then covered with the skin-flap. The flap is not sutured, but kept 
in place by a compress of loose gauze corresponding in size and shape to 
the abscess-cavity. This operation deals more effectually with the me- 
chanical difficulties resulting from imperfect expansion of the lung than 
Estlander's multiple resection of ribs, and will always be resorted to in 
proper cases where less heroic measures have failed in accomplishing the 
desired result. 

LUNG-ABSCESS. 

The successful treatment of abscess of the lung b}' operative pro- 
cedure is one of the many achievements of modern surgery. Bull, of 
Norway, has collected 26 cases of abscess of the lung treated by incision 
and drainage, of which number 4 were cured, 6 improved, 9 relieved, and 
7 were not benefited by the operation. Abscess of the lung is the result 
of a circumscribed suppurative inflammation of lung-tissue, or it de- 
velops after an attack of pneumonia or gangrene of the lung. If it 
follow pneumonia, a part of the solidified organ fails to undergo resolu- 
tion and becomes the seat of secondary infection with pus-microbes. 
The abscess then forms by liquefaction of the inflammatory product, the 
same as in other tissues. Gangrene of the lung can only take place if 
the tissues become infected with putrefactive bacteria through the 
respiratory passages. If the gangrenous portion is limited in extent, 
and life is prolonged for a sufficient length of time, the dead tissue be- 
comes detached, and is frequently eliminated in fragments through a 
bronchial fistula by coughing. The cavity which is formed in this man- 
ner suppurates, and is etiologically and clinically an abscess. A circum- 
scribed suppurative pneumonia, resulting in the formation of an abscess, 
may occur around a foreign body which has lodged in one of the bron- 
chial tubes. The clinical history of every abscess of the lung points to 
an antecedent suppurative pulmonary inflammation, with or without 
gangrene. 

Diagnosis. — The surgeon diagnosticates the existence and location 
of an abscess in the lung by the same methods and means as when it is 
located in another organ. If, from the clinical history and physical 
examination of the chest, he has reason to suspect that the cavity is of 



LUNG-ABSCESS. 317 

a non-tubercular nature, he locates it as accurately as lie can by the physi- 
cal signs which are presented, and then demonstrates, ad oculum, the 
existence of a pus-cavity by exploring the lung with the needle of an 
exploring-syringe. Fenger was the first one in this country to locate an 
abscess of the lung by this means of examination, and to adopt treat- 
ment upon strict antiseptic surgical principles. Microscopical examina- 
tion of the sputum is of great value in determining whether an abscess 
is tubercular or the result of a suppurative inflammation. 

Methodical Exploration of Lung fop Abscess. — If the physical 
symptoms point to a non-tubercular abscess in the lung, with or without 
a bronchial fistula, the surgeon will be able to determine the portion of 
lung involved by ascertaining over the abscess a limited area of dullness 
caused by condensation of lung-tissue around the abscess, and, if the 
abscess-cavity is filled by pus, by the presence of this fluid. If a 
bronchial fistula exist, auscultation will reveal the usual S3'inptoms, 
caused by a cavity in the lung partially filled with blood. B3 7 means 
of percussion and auscultation it is ascertained when the abscess is 
nearest the surface, and at this point the lung is explored with a hollow 
needle, not exceeding in diameter an ordina^ knitting-needle, and at least 
4 inches in length, attached to an ordinary hypodermatic or exploring 
syringe. As a matter of course, the needle and surface must be rendered 
perfectly aseptic before the puncture is made. The needle is pushed 
through an intercostal space, corresponding to the location of the disease, 
in the direction of the centre of the inflammatory focus; its entrance into 
the abscess-cavity is attended by a sudden loss of resistance. Aspiration 
is now made, and if pus is found the diagnosis is made. If no pus is 
withdrawn the needle is pushed forward, and at different points aspira- 
tion is made. If pus is not found in one direction, the needle is partly 
withdrawn and pushed in another direction, and this and additional 
tracks are explored in the same manner until the cavity is located. An 
abscess-cavity only partially filled with pus may be entered at several 
points without finding pus. If the surgeon feel sure that the needle is 
in a cavity, it might be well to make aspiration with the patient in 
different positions, so as to bring the pus in contact with the needle ; or, 
if this fail, to inject a mild antiseptic solution through the needle, which 
will be coughed up if the injection reach the cavity. No operation on 
the lung must be undertaken for abscess until the exact location of the 
abscess has been demonstrated by exploratory puncture. 

Operation. — The first steps of an operation for abscess of the lung 
are the same as in radical operations for empyema. At least a section 
of one rib is removed. With few exceptions, the lung will have become 
adherent to the parietal pleura at the time the operation is undertaken, 



318 PRINCIPLES OF SURGERY. 

but if this is not the case it will become necessary to leave the operation 
unfinished rather than to risk an onset of suppurative pleuritis after the 
lung-abscess has been opened. In such a case, after the parietal pleura 
has been incised, the wound should be tamponed with iodoform gauze, 
and the opening of the abscess postponed until adhesions have formed. 
If adhesions make it safe to complete the operation, the abscess is again 
accurately located by exploring with a needle, and, while the needle is in 
the cavity, the lung is incised with the knife-point of Paquelin's cauteiy, 
using the needle for a guide. By making the incision with the actual 
cautery troublesome parenchymatous haemorrhage is avoided, and at the 
same time the intervening lung-tissue is protected against infection by a 
tubular eschar; and last, but not least, such an opening is better adapted 
for subsequent free and effective drainage. A rubber drain, as large as 
the track made by the cautery, is inserted into the cavity. If the 
abscess communicate with the bronchial tubes irrigation cannot be 
practiced ; if this is not the case the abscess is disinfected by irrigation 
with an antiseptic solution. In either case iodoformization of the abscess- 
cavitjr by dusting the drain with iodoform should always be done. If 
the first opening fail to drain the abscess satisfactorily, it may become 
necessary to make a counter-opening at the most dependent part of the 
cavity and establish another and more efficient point for drainage 
(Vogt-Mosler). 

The after-treatment in cases of lung-abscess treated by incision and 
drainage is the same as after radical operations for empyema. 

SUPPURATIVE PERICARDITIS. 
A suppurative inflammation of the internal surface of the pericar- 
dium results in an abscess of the pericardium, or empyema pericardii. 
The disease is characterized by evidences which indicate the presence of 
a suppurative inflammation and by physical signs which point to the 
presence of fluid in the pericardial sac. In some of the cases which have 
been reported it was attended b}^ little general disturbance, no chill, and 
but little rise of temperature. If it occur as a complication of some 
other affections, the symptoms of the latter often obscure almost com- 
plete^ those of the former. In some of the cases the presence of pus 
was indicated by oedema in the precordial region. If the quantitj- of 
pus is large, the pericardium is distended and the intercostal spaces in 
front of the effusion are more prominent than on the opposite side. The 
area of dullness, which can be mapped out accurately by percussion, 
corresponds with the size of the expanded pericardium. The impulse of 
the heart is felt less distinctly and is more diffuse than in a normal 
condition. A copious pericardial effusion always gives rise to orthopncea 



SUPPURATIVE PERICARDITIS. 319 

Positive proof of the existence of a collection of pus in the pericardium 
can only be obtained by an exploratory puncture. 

Puncture and Aspiration of Pericardium. — Puncture and aspiration 
of fluid from the pericardium is a comparatively harmless procedure, if 
it is practiced with ordinary skill and care. 

West reports 79 cases of paracentesis pericardii. Of this number 
the operation was the cause of death in 1 case only, and in this instance 
the trocar which was used perforated the right ventricle. Six of the 
cases died during the first twenty-four hours, while in the remaining 
cases the immediate effect of the operation was beneficial, and a number 
of cases recovered permanently. In puncture of the pericardium for 
diagnostic or therapeutic purposes, the trocar should always give way to 
a medium-sized needle of an exploring-syringe or aspirator. The punc- 
ture is made under strict antiseptic precautions. The structures to be 
avoided are the internal mammary arteiy, the pleural cavity, and the 
heart. The safest place for puncture is, in ordinary cases, the fifth left 
intercostal space, about half an inch or an inch from the margin of the 
sternum, through which the needle should be pushed in a slightly upward 
and outward direction, so as to avoid wounding the heart. It has to 
travel If to 2 inches before it enters the pericardial cavity. If pus is 
found the case must be treated by 

Incision and Drainage of the Pericardium. — Instead of using a trocar, 
it is much better to make an incision in the fifth intercostal space, using 
the needle with which the exploratory puncture was made as a guide. 
The same precautions to prevent syncope as were recommended in the 
radical operation for empyema should be resorted to in these cases, 
and chloroform is preferable to ether as an anaesthetic. The intercostal 
incision need not exceed an inch in length, and, as soon as the pericardium 
has been opened sufficiently to allow the escape of pus, a dressing 
forceps may be inserted, and the opening enlarged sufficiently to enable 
the introduction of a drainage-tube the size of an ordinary lead-pencil. 

Irrigation of the pericardial cavity is to be avoided unless suppura- 
tion is complicated by putrefaction. The drainage-tube should not 
project sufficiently into the pericardial sac to come in contact with the 
heart, and should always be of soft material, so as not to injure the 
heart should it be too long. The antiseptic dressing can be retained 
most effectually with several strips of rubber adhesive plaster, which 
should be long enough to encircle the whole chest. Stoll, of Warsaw, 
has reported a successful operation for suppurative pericarditis. The 
patient was an exhausted and emaciated soldier, 21 years of age. After 
the sternum was trephined the pericardium was freely opened at the 
level of the second intercostal space. Two months after the operation 



320 PRINCIPLES OF SURGERY. 

examination showed that the pericardial sac was completely obliterated. 
Gussenbauer, in a patient 15 years of age suffering from suppurative 
pericarditis after osteomyelitis, resected part of the fifth rib near the 
sternum before incising the pericardium, and the patient recovered. 
This modification of the ordinary operation by incision through the fifth 
intercostal space will occasionally present decided advantages in the 
surgical treatment of pericardial empyema. 

SUPPURATIVE PERITONITIS. 

A great deal of confusion has recently arisen in the use of the terms 
septic and suppurative peritonitis. Etiological^-, the}' are identical ; 
clinically, they differ in so far that septic peritonitis is generally diffuse, 
and leads to a rapidly fatal termination ; while what is known as suppu- 
rative peritonitis is more frequently circumscribed and more amenable 
to surgical treatment. Both forms are caused by infection with pus- 
microbes. In the septic variety death results from sepsis before the 
pus-microbes have had time to produce their specific pathogenic effect on 
the histological elements which are destined to become converted into 
pus-corpuscles. In suppurative peritonitis the pus-microbes are either 
less in number or they meet with conditions less favorable to the pro- 
duction of a fatal amount of ptomaines, or, finally, the peritoneum is in 
a condition which is unfavorable to the entrance of pus-microbes or their 
toxins into the circulation. 

Bacteriological and Experimental Researches. — A number of original 
investigators have studied the etiology of peritonitis experimentally, 
and their work has been of great practical value in showing that sup- 
purative peritonitis is not only caused by the action of pus-microbes, 
but that it is equally essential that certain conditions must be present 
in the peritoneal cavity which enable the pus-microbes to produce their 
specific pathogenic effects. Pawlowsk}' made ten series of experiments 
on 101 animals. The chemical irritants, or cultures, were introduced 
into the peritoneal cavity through the canula of a small trocar under 
strict antiseptic precautions, and the small wound was carefully sealed 
with iodoform collodion., The first series consisted of experiments 
with croton-oil on 3 dogs and 9 rabbits. The amount of croton-oil 
injected in each case varied from 6 drops to T ^ drop. The smallest 
doses produced no effects. Large doses produced a severe, acute, 
hemorrhagic peritonitis the intensity of which was proportionate to 
the quantity of the irritant injected. The peritoneal exudation, under 
the microscope, was seen to contain red and white blood-corpuscles. 
Inoculations of different nutrient media with the fluid yielded negative 
results. In the next series of experiments an aqueous solution of tryp- 



SUPPURATIVE PERITONITIS. 321 

sin and pancreatin was injected for the purpose of determining whether 
the digestive ferments, in the event of intestinal perforation, could pro- 
duce peritonitis. The experiments established the fact that trypsin acts 
as a powerful irritant upon the peritoneum. Injection of ^ gramme of 
trypsin, dissolved in distilled water, caused in rabbits a severe hsemor- 
rhagic peritonitis, with a copious exudation, and death in from four to 
four and a half hours. In doses of J to T V gramme the same local con- 
dition was produced, but death did not occur until twenty to twenty- 
four hours after the injection. One-hundredth (0.01) of a gramme pro- 
duced no symptoms. Nutrient media inoculated with the products of 
inflammation remained sterile. Next, the peritoneal cavity was infected 
with plate cultures of different microbes suspended in sterilized water. 
The first experiments were made with non-pathogenic microbes. Four 
rabbits and one dog were injected with large quantities of a micrococcus 
which was obtained from a plate culture inoculated with pus ; the micro- 
coccus was exactly similar to the staphylococcus pyogenes albus, for 
which it was first mistaken. Later, it was shown that it was not a pus- 
microbe, as it did not liquefy gelatin. All of the animals recovered. 
Two rabbits inoculated with an entire culture of }^ellow sarcinse upon 
agar-agar, mixed with T 1 ^ drop of croton-oil, also recovered. The ex- 
periments with pathogenic microbes always produced positive results. 
Three series, with three separate microorganisms, were made next. 
The staphylococcus p} r ogenes aureus, grown from osteomyelitic pus, 
was first used. In It out of 41 experiments this microbe alone was 
used ; in 11 it was mixed with croton-oil, in 6 with trypsin, and in 7 with 
agar-agar. In all cases where pure cultures were used peritonitis was 
produced,. the type varying according to the number of microbes used. 
The same microbes could be cultivated upon proper nutrient media from 
the different inflammatory products. In hardened specimens of the 
inflamed peritoneum, stained with different coloring agents, the micro- 
organisms could be seen in the tymph-spaces. The suppurative type of 
peritonitis thus artificially produced became more apparent the longer 
life was prolonged. An entire agar-agar culture of the bacillus pyo- 
cyaneus caused death from septic peritonitis in from twenty-four to 
forty-eight hours. One-fifth of this quantity proved harmless. The next 
series of experiments was made to ascertain the cause of peritonitis 
after intestinal perforation. The fresh intestinal contents of a healthy 
animal, just killed, were divided into three parts, one of which was at 
once injected into several rabbits, without filtration, in doses of 1 
syringeful. The second portion was filtered, and of the filtrate from 2 
to 3 syringefuls were injected into each rabbit. The third portion was 
sterilized, according to Tjmdall's direction, for eight days, and then 1 

21 



322 PRINCIPLES OF SURGERY. 

syringeful was injected into the abdominal cavity of each animal. The 
results were as follow : Four rabbits died of fibrinous, suppurative 
peritonitis from the injections with the first portion. Four rabbits 
injected with the filtered faeces recovered, as did one animal inoculated 
with the sterilized portion. 

At the necropsy particles of the faeces were found in the peritoneal 
cavity covered with fibrin, and a peculiar, short bacillus was found in 
the inflammatory exudate. This bacillus he believed to be the cause of 
peritonitis, and consequently termed it bacillus peritonitidus ex-i?itestinalvs 
cuniculi. The cultures of this bacillus upon agar-agar he describes as 
shining, grayish-white, oil-paint-like colonies. With cultures of this 
bacillus he made 9 experiments on rabbits and 2 on dogs. Every 
animal which received an entire agar-agar culture died of hsemorrhagic 
peritonitis in from twenty to twenty-four hours. In smaller quantities, 
death from the same cause sometimes did not occur until at the end of 
the third day. Still smaller doses produced a suppurative peritonitis 
and death after a number of da3 r s. Of the 2 dogs, each injected with an 
agar-agar culture, 1 died after twenty-four hours of septic peritonitis, 
the other recovered after an illness of several days' duration. In the 
fatal cases the bacillus was found in different organs, and could again 
be reproduced by inoculations with infected tissues upon nutrient media. 
This author maintains that the fibrinous form of peritonitis is the least 
dangerous, as the layers of fibrin tend to limit the entrance of microbes 
into the circulation, while thejr also retard the local diffusion of the in- 
jection. The fibrino-suppurative variety is the next least dangerous 
form, while in the most rapidly fatal cases of septic peritonitis the local 
lesion is not characterized by any macroseopical tissue changes. Wegner 
has shown by his experiments that a great variety of fluids from septic 
microbes, such as water, bile, urine, blood, etc., can be injected into the 
peritoneal cavity of rabbits without any serious results following ; even 
large quantities of unfiltered air, when introduced in the same manner, 
proved innocuous. Putrescible substances, when injected in small quan- 
tities, were rapidty absorbed without producing peritonitis; but when 
the quantity injected was large, and insufflation of unfiltered air was 
practiced at the same time, peritonitis, with putrefaction and death from 
septic intoxication, occurred. Grawitz proved that saprophytic bacteria, 
when injected into a normal peritoneal cavity, were promptly destroyed 
and absorbed. In cases in which the injection was made into a perito- 
neal cavity which had previously undergone alterations by injury or dis- 
ease, or in which the quantity of fluid was too great for speedy absorp- 
tion, symptoms of intoxication, as described b} T Weber, resulted, but 
these symptoms were unaccompanied by suppurative peritonitis. A 



SUPPURATIVE PERITONITIS. 323 

healthy peritoneal cavit}' has also been found capable of disposing of a 
limited quantity of pure cultivations of pus-microbes, the microbes 
being removed by absorption and destroyed in the circulation or elimi- 
nated through the excretory organs. But when pyogenic organisms are 
introduced into an abdominal cavit}^ in which the absorptive capacity 
of the peritoneum has been diminished or suspended by antecedent 
pathological conditions, suppurative peritonitis is the usual result. 
When pus-microbes are introduced in large quantities, even into a 
healthy peritoneal cavity, the preformed toxins, by their chemical 
action, so alter the tissues that the process of absorption is impaired, 
and suppurative peritonitis again results in consequence of the retention 
of pus-microbes in tissues prepared for their pathogenic action. 

Orth agrees with Grawitz, that when a pure culture is injected into 
a healthy peritoneal cavity suppuration does not necessarily take place. 
But his experiments prove, what is of the greatest practical interest, that, 
if the peritoneum is wounded under antiseptic precautions, peritonitis 
invariably follows, if suppuration exist elsewhere in the body at the 
same time. If, for instance, an abscess in the subcutaneous tissue was 
artificially produced in animals and then the intestine was rendered tem- 
porarily impermeable, death from suppurative peritonitis was the rule. 
The same result followed if the pus-microbes were injected directly into 
the circulation, but not if they were introduced through the alimentary 
canal. Rinne is of the opinion that, on account of the rapidity with 
which absorption takes place in the peritoneal cavity, the peritoneum, 
when in a normal condition, is almost immune to infection with pus- 
microbes. He injected from 30 to 35 cubic centimetres of a pure culture 
of pus-microbes, suspended in sterilized water, into the peritoneal cavity 
of healthy animals, and never succeeded, in this manner, in producing 
peritonitis. He had no better success with injections of a mixture of a 
gelatin culture of staphylococcus pyogenes aureus and a turbid bouillon 
culture of the same coccus. He also made daily injections with a putrid 
fluid, to which was added a culture of the staphylococcus pyogenes 
aureus, without producing peritonitis. The experiments, as a rule, were 
made on dogs, although, in several instances, rabbits, guinea-pigs, and 
white rats were used. He believes that the difference in the results ob- 
tained bj r him and Grawitz, as compared with Pawlowskv, consists in 
the nature of the abdominal wound. Pawlowsky made an incision down 
to the muscles and then perforated the abdominal wall with a blunt 
trocar; while he and Grawitz used a sharp, hollow needle for making the 
intra-peritoneal injection. To prove that his injections reached the 
peritoneal cavity, he added coal-dust to the fluid, which he found at the 
post-mortems as fine particles clinging to the peritoneal surface. 



324 PRINCIPLES OF SURGERY. 

Clinical and Bacteriological Studies.— Frankel found the strepto- 
coccus pyogenes in a great variety of puerperal diseases, especially in 
cases in which the local affection implicated the lymphatic vessels. In 
such cases the microbes found entrance into the pelvic tissues from abra- 
sions or nlcers in the vagina, and by extension of the inflammatory 
process the broad ligaments and the peritoneum are successively reached ; 
after the peritoneum has once been reached rapid diffusion takes place, 
and, finally, the diaphragm and pleura are implicated in the same process, 
and the microbes reach the blood and cause sepsis and pyaemia. 

In suppurative peritonitis without the existence of a direct com- 
munication with the external surface or the intestinal canal we must take 
it for granted that pus-microbes may have entered the peritoneal cavity 
through the Fallopian tubes, through slight defects of the intestinal 
mucous membrane, and from here through the lymphatic channels into 
the peritoneal cavity, or through a minute perforation the existence of 
which cannot be demonstrated during life and often not at the post- 
mortem examination, or, finally, localization of pus-microbes from the 
blood in the capillaries of the peritoneum. Weichselbaum has shown 
that peritonitis is not always caused by pus-microbes, as has been here- 
tofore believed, as he found the diplococcus of pneumonia unaccompanied 
by any other microorganism in 3 cases of peritonitis. In 1 case peri- 
tonitis and pneumonia existed at the same time; in the other double 
pleuritis followed the peritonitis ; but in the last case peritonitis was 
undoubtedly primaiy, and, in the absence of any other microbes in the 
products of the inflammation, must have been caused by the diplococcus 
of Friedlander. In another case following rupture of the spleen in the 
course of typhoid fever he obtained from the exudate a pure culture of the 
typhoid bacillus. Frankel made recently a bacteriological study of 31 
cases of peritonitis, with the following result : Bacillus coli communis, 
nine times; streptococci, seven times; bacillus lactis aerogenes, twice; 
micrococcus pneumoniae composae, once; staphj'lococcus pyogenes aureus, 
once. In 3 cases bacillus coli communis was present in association with 
other bacilli, and in 4 cases the bacteriological examination yielded a 
negative result. There can be no doubt that septic peritonitis may 
be caused by pathogenic microbes which, at present at least, are not 
classified with the pus-microbes ; but suppurative peritonitis can have no 
other bacteriological cause, and in most cases of septic peritonitis in- 
fection with pus-microbes can be demonstrated by clinical evidences as 
well as bacteriological and experimental demonstration. 

Difference between Plastic and Suppurative Peritonitis. — The great- 
est clinical difference between simple or plastic peritonitis produced by 
trauma or chemical irritants and septic or suppurative peritonitis con- 



SUPPURATIVE PERITONITIS. 325 

sists in the cause and extent of the inflammation. Plastic inflammation 
produced by aseptic causes remains limited to the seat of trauma or 
chemical irritation, and does not extend much beyond the surface-area 
to which the stimulus is applied ; while septic peritonitis is always char- 
acterized by its progressive character, as the cause upon which it de- 
pends is reproduced within the peritoneal cavity. A plastic peritonitis 
is attended by febrile disturbances, caused by the introduction into the 
circulation of the products of coagulation necrosis or metabolic tissue 
changes; in septic peritonitis the general s3'inptoms are produced by 
the entrance of pus-microbes into the general circulation and their 
toxins, both of which are also reproduced in the blood and other organs 
of the body in which secondary localization may take place. 

The Cause of Suppurative Peritonitis. — Experimental research has 
demonstrated that in the causation of suppurative peritonitis two con- 
ditions must be present at the same time: 1. Pyogenic bacteria. 2. A 
wound of the peritoneal surface, or antecedent pathological conditions 
which diminish the absorptive capacity of the peritoneum. The microbic 
cause is the essential etiological factor, as without it the other conditions 
would not result in this form of peritonitis. If pus-microbes are intro- 
duced into the peritoneal cavity in sufficient quantity suppurative 
peritonitis is produced, as the preformed toxins create the indirect 
etiological conditions. A number of bacteria which at present are not 
classified with the pus-microbes may, under certain favorable conditions, 
manifest pyogenic properties ; and thus, when introduced into a peritoneal 
cavity predisposed to suppuration, cause an attack of suppurative peri- 
tonitis. Thus we have seen that Weichselbaum has found the diplo- 
coccus of pneumonia in the inflammatory product of three cases of 
peritonitis, and as no other microbes were present it is reasonable to 
assume that suppuration was caused by this microbe. In serous cavities 
gonorrhoea! pus produces, as a rule, a circumscribed abscess. Sinclair, 
in his excellent monograph on " Gonorrhceal Infection in Women," after 
describing the gonorrhceal infection from the vagina, says: " The proper 
character and the result of the pathogenous activit}?" of the gonorrhceic 
microbes are therefore seen, pure and unadulterated, in the tube. They 
cause purulent inflammation of the mucous membrane, but the surround- 
ing connective tissue remains free from them. The gonorrhceic tubal 
pus is evacuated into the peritoneum, and, whereas in other conditions 
the bursting of an abscess into the abdominal cavity is followed by the 
gravest consequences, in this case the whole process terminates with a 
circumscribed inflammation, encapsuling the exuded pus. The cause of 
this difference is the var} T ing pathogenic value of the organisms which 
are contained in the pus. A puerperal pelvic cellulitic abscess, bursting 



326 PRINCIPLES OF SURGERY. 

into the peritoneum, causes general peritonitis, because it contains 
pyogenous streptococci, which rapidly multiply in serous cavities and 
are capable of exerting the most deleterious effects. Gonorrhoeal tubal 
pus cannot do this ; its microbes do not find in the peritoneum con- 
ditions for their increase ; the pus, therefore, acts as an aseptic foreign 
body, becomes encapsuled, and is finalty absorbed. Practicall} T , itjs well 
known that when gonorrhoeal infection extends from the Fallopian tubes 
to the peritoneum by leakage of pus into the peritoneal cavity from 
the peritoneal extremity of the tube, or rupture of a pus-tube, the 
result is a circumscribed suppurative peritonitis, with the formation of 
a circumscribed abscess." 

Wertheim's recent investigations have shown that the gonococcus 
can set up a peritonitis in animals whose mucous membranes are re- 
fractory to the action of this microbe. From this it follows that the 
gonococcus will produce peritonitis in man whose mucous membranes 
are very susceptible to gonorrhoeal inflammation. He has also demon- 
strated that the gonococcus can penetrate pavement as well as cylindrical 
epithelium. Under certain favorable circumstances it also gains entrance 
into the lymphatics. 

That encapsulation of gonorrhoeal pus does not invariably follow 
gonorrhoeal infection of the peritoneal cavity is well shown by a case re- 
ported by Loven, which is by no means an isolated one. The source of 
infection could not be learned in this case, but the diagnosis of gonorrhoeic 
ascending infection was positive. The disease commenced as an ordinary 
vulvo-vaginal blennorrhoea, which consecutively extended to the uterus, 
Fallopian tubes, and terminated in pelvic and diffuse peritonitis. It is 
possible that in this particular case a secondary infection with pus- 
microbes had taken place, as, at the necropsy, chain cocci were found in 
the peritoneal cavity. The relation of the streptococcus of erysipelas to 
peritonitis will be considered in the chapter on Erysipelas. Abdominal 
surgeons are very well aware of the clinical fact that septic or sup- 
purative peritonitis, after laparotomy, is more prone to develop if fluids, 
and especially blood, are allowed to remain in the abdominal cavity ; and 
consequently resort to a careful toilet of the cavity, and, if there is any 
reason to expect a re-accumulation, to drainage. Fluid in the peritoneal 
cavity prevents the removal of the pus-microbes b} r absorption, and if 
they remain they multiply and cause peritonitis. For years it has been 
customary to resort to the use of opium in the prevention and treatment 
of peritonitis, until Tait showed the fallacy of such treatment and recom- 
mended cathartics in threatened cases of peritonitis. The treatment 
of incipient peritonitis by a brisk saline cathartic is now generally 
practiced, and the results have been exceedingly sat is factor}^. What is 



SUPPURATIVE PERITONITIS. 327 

the modus operandi of saline cathartics in the prevention of diffuse 
septic peritonitis ? The most rational answer to this question is that a 
brisk saline cathartic promotes absorption of fluids from the peritoneal 
cavity, and by so doing removes the indirect causes of peritonitis, and, 
at the same time, favors the elimination of pyogenic microbes. Intra- 
abdominal wounds not covered with peritoneum are potent factors in the 
development of peritonitis in an abdominal cavity which is not abso- 
lutely aseptic, as the raw surfaces furnish a considerable quantity of 
wound-secretion, on the one hand, and, on the other, diminish the ab- 
sorptive capacity of the peritoneum. This cause of peritonitis should 
be avoided as far as possible, in all intra-abdominal operations, by avoid- 
ing unnecessary injury to the peritoneum, and by covering denuded sur- 
faces with this membrane wherever it can be done. Another indirect 
cause of peritonitis is intestinal obstruction. The intestine above the 
seat of obstruction becomes dilated, congested, softened, and, in con- 
sequence of these changes, permeable to pathogenic microbes, which are 
always present in the intestinal canal under these circumstances. 

Alapy has made a series of experiments in Weichselbaum's labora- 
tory to ascertain if pathogenic microbes could pass through the healthy 
stomach into the intestines. He experimented with pus-microbes and 
the streptococcus of erysipelas. From these experiments he came to the 
conclusion that the virulence of these microbes is destroyed in a healthy 
stomach, but when the gastric secretion has suffered diminution of 
acidity, or has become alkaline, the microbes do not lose their patho- 
genic properties, and pass into the intestines in an active condition. In 
cases of intestinal obstruction the pl^siological functions of the stomach 
are disturbed, and conditions are created which preserve the virulence 
of pathogenic microorganisms on their way into the intestinal canal. 
The immediate cause of death in many cases of intestinal obstruction is 
diffuse septic peritonitis. In the different forms of perforative perito- 
nitis the disease is caused by the escape of fluids containing pyogenic 
bacteria, and the type and gravity of the disease is greatly modified by 
the amount of fluid which enters the peritoneal cavity and the number 
of microbes which it contains. Perforation of a typhoid or tubercular 
ulcer is always a grave occurrence, as the fluid which escapes is usually 
considerable in quantity and contains numerous pathogenic microbes. 
Perforating ulcer of the stomach is more frequently followed by circum- 
scribed plastic peritonitis, which shuts out the general peritoneal cavity. 
Perforation of the appendix vermiformis is followed as often by circum- 
scribed suppurative peritonitis as by diffuse septic peritonitis. The same 
can be said of perforation of the gall-bladder. 

Symptoms and Diagnosis. —Diffuse septic peritonitis spreads over 



328 PRINCIPLES OF SURGERY. 

the entire peritoneal cavity almost with lightning speed. The first 
symptoms are those of shock. If the disease follow an abdominal 
section, it is often difficult to determine whether the conditions presented 
are due to shock or diffuse peritonitis, as the latter maj- set in in a few 
hours after the operation and prove fatal within twenty-four hours. 
The temperature is variable. It may remain normal or become even 
subnormal, or it may at first be only slightly increased and gradually 
reach 102° to 104° F. Vomiting and diarrhoea are frequently conspicuous 
symptoms. In other cases the symptoms point to intestinal obstruction. 
In extensive plastic peritonitis the immobilization of a considerable 
portion of the small intestine may give rise to persistent vomiting and 
absolute constipation. Again, arrest of the faecal circulation ma}' be 
caused by the tympanites alone, while perforative peritonitis is attended 
by a local and general shock, which causes intestinal paresis through the 
sympathetic nerves. Heusner has observed that perforative peritonitis 
gives rise to disturbances simulating intestinal obstruction by arresting 
intestinal movements. He narrates the histories of 2 cases of this 
kind in which the symptoms of intestinal obstruction were so prominent 
that laparotoni3 r was performed. In both cases perforative peritonitis, 
but not occlusion, was found. Hen rot, in his classical monograph on 
" Pseudo-Strangulation," describes a number of cases of perforation of 
the gall-bladder and the processus vermiformis, where the S3^mptoms 
during life had pointed so strongly to the existence of intestinal obstruc- 
tion that a wrong diagnosis was made b} r able clinicians. He also calls 
attention to those cases of paralytic obstruction which are often observed 
after herniotomy, and in cases of strangulation of the appendix vermi- 
formis and testicle. The intestinal paresis, where it is not the result of 
inflammation, must be looked upon as a reflex symptom. 

Physical signs and symptoms are sometimes utterly inadequate to 
distinguish between acute intestinal obstruction and diffuse peritonitis. 
In differentiating between these two conditions, it must be remembered 
that, in the absence of a tumor, absolute constipation and faecal vomiting 
are the most characteristic symptoms of obstruction, and that in peri- 
tonitis the pain is severe and continuous, with diffuse tenderness, 
tympanites, and absence of visible intestinal coils. In mechanical 
obstruction of the bowels the temperature is, as a rule, not above normal 
unless complications have set in ; while in peritonitis a rise in tempera- 
ture is the rule, although in some of the gravest cases it is subnormal. 
Many cases of alleged recovery from intestinal obstruction without 
operation undoubtedly were cases of dynamic obstruction, and the 
recovery was either entirely spontaneous or facilitated by means which 
assisted in the restoration of peristaltic action. In 1851 a patient was 



SUPPURATIVE PERITONITIS. 329 

admitted into Dupuytren's ward with well-marked symptoms of acute 
intestinal obstruction. This eminent surgeon gave it as his opinion that 
without an operation a fatal termination was inevitable, but the patient 
objected to the operation and was transferred to another ward, where he 
recovered in three days under the use of simple cathartics. 

Numerous similar cases could be cited in illustration of the difficulty 
of differentiating in all cases between mechanical occlusion and dynamic 
obstruction. In cases of perforative peritonitis and peritonitis with 
putrefaction the presence of gas in the free peritoneal cavity gives rise 
to an important physical sign. In tympanites from peritonitis without 
perforation and intestinal obstruction, the distended intestines push the 
liver in an upward direction; hence, on percussion, the liver dullness is 
transferred higher up. But, under the circumstances mentioned above, 
the gas in the free abdominal cavity occupies the space between the 
liver and the chest-wall; consequently, the liver dullness has dis- 
appeared and the space over the organ is tympanitic on percussion. One 
of the most constant signs in peritonitis is the small, rapid, compressible 
pulse. In diffuse peritonitis it usually ranges between 120 and 140. 
In rapidly fatal diffuse septic peritonitis pain is often wanting. In 
circumscribed peritonitis pain and tenderness are limited to the affected 
region. Tympanites is often a most distressing symptom in circum- 
scribed peritonitis, and may be entirely absent in the most fatal form 
of septic peritonitis. Rigidity of the abdominal muscles is an indi- 
cation of peritonitis, while it is absent in uncomplicated intestinal 
obstruction. In suppurative peritonitis the presence of pus in con- 
siderable quantity is indicated by the physical symptoms arising from 
the accumulation of fluid, either in the free peritoneal cavity or in a 
circumscribed space of it. If the pus is not confined by adherent 
intestines and plastic exudation, it will gravitate toward the most 
dependent portion of the peritoneal cavity, and on this account the 
area of dullness will vary according to the position of the patient. In 
circumscribed suppurative peritonitis the pus is confined in a limited 
space b}^ adherent abdominal organs and fibrinous exudation, and will 
then present all the signs and sj^mptoms of a deep-seated abscess. To 
determine the character of peritoneal effusion, or of the contents of a 
circumscribed intra-peritoneal inflammatory swelling, it is necessary to 
resort to an exploratory puncture. The needle is inserted at a point 
where the fluid is in contact with the abdominal wall, and, in the circum- 
scribed form of peritonitis, in a place where the puncture can be made 
without traversing the free peritoneal cavit}^. 

Treatment. — In perforative peritonitis cathartics are absolute^ con- 
tra-indicated, as increased peristalsis would aggravate the existing con- 



330 PRINCIPLES OF SURGERY. 

ditions by increasing- the extravasation and by preventing limitation of 
the infection. In such cases opium should be administered to diminish 
the peristalsis, to relieve pain, and to diminish shock. The subsequent 
safety of the patient will rest on an early radical treatment by laparot- 
omy. Unless the location of the perforation can be ascertained before- 
hand, the incision should be made in the median line. In cases of 
perforation of the appendix vermiformis an incision extending from the 
middle of Poupart's ligament to a point half-way between the anterior- 
superior spinous process of the ilium and umbilicus will secure most 
direct access to the seat of perforation. Perforating tubercular and 
typhoid ulcers are found most frequently in the ileo-csecal region. If, on 
opening the abdominal cavity, the perforation cannot be readily found, it 
is better to resort to rectal insufflation of hydrogen-gas at once, which 
will show with unfailing certainty not only that a perforation exists, but 
also its exact location. In multiple perforations the same diagnostic 
test is almost indispensable, as it will avoid the great mistake of leaving 
a perforation un sutured. The perforations are treated in the same man- 
ner as an incised wound. Care must be taken to suture the opening in 
a direction that will interfere the least with the lumen of the intestine. 
Fine aseptic silk should always be used in preference to catgut ; at least 
two rows of sutures must be applied. 

After suturing the perforation the abdominal cavity is washed out 
freely with sterilized water. Drainage in these cases must never be 
omitted, as the operator has no assurance that the peritoneal cavity has 
been rendered perfectly aseptic. A threatened septic peritonitis after 
laparotomy can often be aborted by giving half an ounce of sulphate of 
magnesia, dissolved in a glassful of water, upon the appearance of the 
first sj^mptoms. The action of the saline cathartic can be hastened and 
its beneficial effects increased by the administration of a turpentine 
enema. After the bowels have been moved thoroughly opium can be 
given in sufficient doses to relieve pain. If the symptoms do not sub- 
side under this treatment, the abdominal wound is opened sufficiently to 
permit free irrigation with salicylated water, and a Keith drain is in- 
serted, loosely packed with iodoform gauze, and a copious hygroscopic 
antiseptic dressing applied. Many surgeons of the present time doubt 
the occurrence of peritonitis without a local source of infection, and 
there can be no doubt that so-called spontaneous peritonitis without 
such a local focus is exceedingly rare, but its existence cannot be denied. 
If suppuration in a joint, in the pleural cavity, or in the pericardium can 
occur without such a direct local cause, there is no reason why suppura- 
tive peritonitis should not, at least in exceptional cases, have a similar 
origin. A locus minoris resistentise of a non-suppurative type in any 



SUPPURATIVE PERITONITIS. 331 

part of the peritoneal cavity can determine localization of pus-microbes 
here as well as in any other part of the body. In opening the abdomen 
for the evacuation of pus, the surgeon must look for a primary lesion ; 
but he will not always find it, as it is not invariably present. Diffuse 
septic and suppurative peritonitis are seldom, if ever, cured by laparot- 
omy. Localized suppurative peritonitis brought about by curable causes 
is amenable to successful surgical treatment. An operation is alwa} r s 
indicated as soon as the presence of pus is ascertained. Delay is dan- 
gerous in these cases, as the delicate walls, composed of plastic exuda- 
tion, may yield to the pressure, and the extravasation of pus infects a 
new portion of the peritoneal cavity, or perhaps its entire extent. In 
circumscribed suppurative peritonitis the incision is to be made at a 
point where the pus is in contact with the abdominal wall. The abdomen 
is to be opened by a careful dissection, and if the incision lead directly 
into the pus-cavity this is drained and washed out with sterilized water 
or a weak antiseptic solution. If, on cutting through the peritoneum, 
no pus is found, and the peritoneal cavity has been opened, it is not safe 
to evacuate the pus until the peritoneal cavity has been shut out by 
suturing the abscess-wall to the parietal peritoneum, or packing the 
wound for a few days with iodoform gauze, and postponing the opening 
of the abscess until firm adhesions have formed between the margins of 
the wound and the surface of the abscess-wall. This method of oper- 
ating in two stages must be frequently resorted to in the treatment of 
pelvic abscess, abscess of the liver, and empyema of the gall-bladder. 
If the primary disease which has caused the intra-peritoneal suppuration 
can be discovered, this must receive special attention. In circumscribed 
suppurative peritonitis in the right iliac region caused by perforation of 
the appendix vermiformis the appendix must be looked for, and when 
found perforated it is excised near its attachment to the caecum, after 
tying its base with a fine-silk ligature ; or, if this cannot be done, it ma} r 
be slit open and drained, as was done successfully by Tait. All oper- 
ations for suppurative peritonitis are to be conducted upon rigid anti- 
septic principles, and antiseptic measures are to be followed without 
relaxation during the entire after-treatment. As patients suffering 
from peritonitis are always greatly debilitated from the effects of the 
disease as well as from lack of solid food, which, for well-founded 
reasons, must be withheld, every effort should be made to sustain 
strength by the systematic administration of liquid nourishment and 
alcoholic stimulants. Absolute rest must be enforced for the purpose 
of limiting the extension of the disease and with a view of aiding the 
process of repair. 



CHAPTER XIII. 

Septicemia. 

Septicemia, septaemia, sepsis, are synonymous terms used to desig- 
nate a general febrile affection caused by the introduction into the 
circulation of the products of fermentation or putrefaction, and which 
is characterized by definite blood-changes, a typical series of inflamma- 
tory processes, a peculiar group of nervous symptoms and critical 
discharges. Clinically, and probably etiologically, it is closely related 
to pyaemia. The older pathologists entertained the belief that in cases 
of septicaemia the blood itself was the seat of putrefactive changes. At 
present it is generally conceded that it results from the introduction into 
the circulation of septic microorganisms or their ptomaines. The 
symptoms do not suffice for a full characterization of the disease, but 
the specific infection is the integral and essential factor. 

BACTERIOLOGICAL RESEARCHES. 

Septic processes were among the first to excite interest in the part 
played by microorganisms in disease. Although some of the best 
pathologists have been diligently investigating this subject for years, we 
still remain in the dark concerning its true etiology and its relation to 
other infective processes. True sepsis is now regarded as a general 
infection from some local source, unattended by any gross pathological 
changes. Some writers have claimed the etiological difference between 
septicaemia and pyaemia to be a quantitative and not a qualitative one, 
while others maintain that pyaemia is a specific disease sui generis, and 
that it is in no wise related to sepsis. There can be no doubt that true 
progressive sepsis, if not invariably, is, at least frequently, caused by the 
same microbes which produce pj-aemia. As we have seen in the fore- 
going chapter, the same microbes, when introduced into the peritoneal 
cavity, may either cause a circumscribed suppurative peritonitis or a 
diffuse septic peritonitis, with all the clinical features of progressive 
sepsis. The first reliable investigations into the microbic origin of 
sepsis were made by Rindfleisch in 1866, and, somewhat later, hy Klebs, 
Recklinghausen, Waldeyer, and Hueter. Rindfleisch found bacteria in 
abscesses, while the researches of Klebs initiated a new era in the etiology 
of septic diseases. Klebs differentiated between septicaemia and pjaemia, 
although he claimed that putrid intoxication and septic infection were 
the same. In the tissues altered b} 7 septic processes, and in the lymph- 
(332) 



BACTERIOLOGICAL RESEARCHES. 333 

spaces and in the blood, he found a microbe, a round coccus, isolated and 
in groups, which he termed mikrosporon septicum. 

Septicaemia in Mice. — One of the best descriptions of true pro- 
gressive septicaemia that has ever been given is by Koch on septicaemia 
in mice. He used the same method which was followed by Coze, Feltz, 
and Davaine. He injected putrid fluids, decomposed blood, putrefying 
blood, under the skin in mice. He found that the virulence of these 
fluids was attenuated by age. Blood that had putrefied only for a few 
days, in 5-drop doses, killed a mouse within a short time. In this case 
marked symptoms were observed in the animal immediately after the 
injection. 

The animal became very restless, running about constant^, but 
showing great muscular prostration and uncertainty in all its movements ; 
it refused food, the respiration became irregular and slow, and death 
took place within eight hours. The greater portion of the fluid injected 
was found, after death, not to have been absorbed. No inflammation at 
the seat of injection. No macroscopical pathological changes were 
found in any of the internal organs. Blood taken from the right auricle 
and injected into another mouse produced no symptoms. No bacteria 
could be found in the blood or any of the internal organs. Koch con- 
cluded that death was not caused by bacteria, but by the introduction 
into the circulation of a preformed poison contained in the putrid fluid, 
as when smaller doses were used the symptoms of intoxication were less 
marked, and when the quantity was reduced to 1 drop the animal often 
recovered without manifesting any morbid sj^mptoms. About one-third 
of the animals which had received 1 or 2 drops of the fluid subcutane- 
ously remained well for about twenty-four hours, when an increased 
secretion from the conjunctiva was observed ; at the same time the 
animal showed signs of great muscular weakness. It then ceased to 
take food ; its respirations became slower, prostration became more and 
more marked, and death came on almost imperceptibly. After death the 
animal remained in the sitting posture with its back strongly bent. 
Death occurred in from forty to sixty hours after inoculation. The only 
post-mortem change noticed was a slight subcutaneous oedema at the 
point of injection, and this was not constantly present. 

Koch then experimented with the oedema-fluid and blood of mice 
that had died of sepsis, ^ drop of which was injected into another 
mouse, when exactly the same symptoms and result were produced in 
the latter animal, after the same lapse of time and in the same order as 
in the former. 

From this second animal a third was infected in like manner, with 
identical results. Successive inoculations proved that the virus could be 



334 



PRINCIPLES OF SURGERY. 



propagated indefinitely from animal to animal without losing its viru- 
lence. He could communicate the disease with certaint}^ by passing the 
point of a scalpel, which had been in contact with the infected blood, 
over a small wound of the skin. The blood of the animals which became 




B '^/~ 












^.SSU, 






* tf ^i\*" 



\ ST. ' 



v>s — 



_% I-TS 



l-j / 



B «£-- •&• - -- -c_ - M 









^r~& :''-' *-A's ^J 1 ^^' :-W^^^^k 




Fig. 112.— Vein of the Diaphragm of a Septicemic Mouse. X700. {Koch.)* 

A, nuclei of the vascular wall ; B, septicemic bacilli ; C, white blood-corpuscles which have become transformed 
into masses of bacilli ; D, capillaries opening into vein. 

ill after injection of 1 to 10 drops of putrefj'ing blood was found to 
contain, as a rule, different varieties of bacteria in small numbers, micro' 

* Figs. 112, 114, and 115 are copied from "Traumatic Infective Diseases," by permission 
of the New Sydenham Society, London. 



BACTERIOLOGICAL RESEARCHES. 335 

cocci, and large and small bacilli. If, however, it died after inoculation 
with putrefying or septicemic blood, small bacilli alone appeared in the 
blood. > This result was constant, and the bacilli were always in large 
numbers. These bacilli lie singty or in small groups between the red 
blood-corpuscles. One can often see the bacilli in septicemic blood 
attached to each other in pairs, either in straight lines or forming an 
obtuse angle. In some cases Koch has also seen spores in the bacilli. 
Their relation to the white corpuscles is peculiar. They penetrate into 
these and multiply in their interior. 

Microscopical examination of the tissues at the point of inoculation 
showed that the bacilli entered the capillary blood-vessels, where they 
caused such extensive alterations as to give rise to extravasation of 
numerous red blood-corpuscles. They were never found in the lymphatic 
vessels. Within the blood-vessels the}' are almost always arranged with 
their long axis in the direction of the blood-current. In the capillaries 
the bacilli congregate, particularly at the point of division, but never 
cause complete obstruction. Rabbits and field- 
mice proved immune to inoculations with the 
septicsemic blood of the domestic mouse. The 
bacillus of Koch's septicaemia can be cultivated 
upon a mixture of aqueous humor and gelatin, 

or of gelatin, peptone (1 per cent.), salt (0.6 per 

& i-r i v r n v x p IG ii3_ Bacillus of 

cent.), and sodium phosphate in sufficient mouse-septic-emia. 

/7 x l Single Colony in 

quantity to render the mass alkaline in reaction. nutrient gelatin. 

^ J X 80. {Fluegge.) 

The bacilli grow well upon this mixture, and by 
repeated and rapid division form peculiar branched series. 

Septicaemia in Rabbits. — Although Koch was unable to produce sep- 
ticaemia in rabbits, either by injections or inoculations of septicemic 
products from the domestic mouse, he caused the disease artificially by 
injecting a putrid infusion of meat. In these cases the injection pro- 
duced extensive suppuration, with putrefaction, and the animals died in 
three days and a half. Various bacteria were found in the inflammatory 
product. At the border of the local inflammation the connective tissue 
was infiltrated with a turbid, serous fluid, which contrasted strongly 
with the brownish offensive pus. In this oedema-fluid only cocci of 
an oval form were found. In the blood similar microbes were found, 
though only in small numbers. Some of the small veins in the 
spleen and kidnej^s were seen to be completely blocked with the same 
microbe. 

Two drops of the oedema-fluid were injected under the skin of the 
back of a second rabbit. The animal died in twent3*-two hours, and 
here, in the vicinity of the injection, not a trace of suppuration could be 




336 



PRINCIPLES OF SURGERY. 



found. Hemorrhagic extravasations were found in the inflamed 
oedematous connective tissue. No alterations were found in the heart 
and lungs. In this animal the oval micrococci were alone present 
in the oedema-fluid. Micrococci were also found in the capillary ves- 
sels in different organs ; in some of them the lumen of the vessels 
was completely blocked. In the capillary vessels surrounding the 




Fig. 114.— Glomerulus of a Septicemic Rabbit. X700. (Koch.) 

A, capillary loop with oval micrococci spread oiit like a membrane ; B, micrococci deposited on the 
walls of a capillary vessel ; C, loop completely filled with micrococci; D, individual micrococci in a 
oapillary vessel near a glomerulus. 



intestinal glands numerous obstructing masses of the bacilli were 
present. 

At many points these were so extensive that branching accumula- 
tions were seen consisting entirely of these organisms. This microbe 
was never seen to inclose blood-corpuscles, and, as they did not cause 
coagulation of the blood, embolism was never observed. The virulence 
of the bacillus was not, increased by successive inoculation with infected 



BACTERIOLOGICAL RESEARCHES. 



337 



blood from animal to animal. The bacillus now under consideration ap- 
pears to be closely allied or identical with that of Davaine's septicaemia, 
which was first produced by injecting rabbits with putrid ox-blood. The 
two diseases are distinguished in that Davaine's septicaemia is easily trans- 
missible to guinea-pigs, but not to birds; while mice, pigeons, fowls, and 
sparrows are very susceptible to the bacillus of septicaemia in rabbits, 
discovered by Koch, but guinea-pigs, dogs, and rats resist. Hueppe be- 
lieves that this microbe is not a bacillus, but a coccus in a state of elonga- 




Fig. 115.— Capillary Vessels Surrounding the Intestinal Glands of a 
Septicemic Rabbit. X700. (Koch.) 



tion; and Gaffky,Sclmetz. Kitt, Salmon, Fluegge, and Baumgarten classify 
it with the bacilli. It readily stains in aniline solutions. Upon sterilized 
gelatin it grows in the form of clear, finely-granular drops, which, when 
they become confluent, form a culture which appears as a grayish-white 
film with jagged borders. Liquefaction of the gelatin never takes place. 
It can also be cultivated upon agar-agar, coagulated blood-serum, and 
potato. Gaffky investigated Davaine's septicaemia experimentally. He 
procured the infection by using water from a stagnant rivulet, and, Ity 
continually controlling the experiments with the microscope, using 

22 



338 



PRINCIPLES OF SURGERY. 



Koch's methods, and working only with pure cultures, he was able to 
prove beyond a doubt that the theories of progressive virulence of bac- 
teria were untenable. He showed that the highest degree of virulence 
was already attained in the second generation. He pointed out that the 
fallacious conclusions were due to impurification in the experiments, and 
that when the proper precautions are taken, in the process of steriliza- 
tion, to prevent the admixture of other microorganisms, the introduc- 
tion of one kind always produces in the same animal the same definite 
result. 

The most interesting conclusions to be drawn from the experi- 
ments in Koch's laboratory point to the fact that septicaemia is only 
a general term which includes a number of morbid processes, and this 
is well illustrated by the injection into the tissues of the " vibriones sep- 
tiques " of Pasteur. Surface inoculations with these bacilli produce no 
effect ; their pathogenic influence became only evident after injections into 
the subcutaneous connective tissue. Gaffky found that this bacillus 
a b grows most readily upon potato. Koch 

applied to the condition produced by 
this bacillus the term " malignant 
oedema." 







\ 



Fig. 116.-BACit,iiUS of Malignant CEdema. 
X700. {Koch.) 

A, from the spleen of a guinea-pig ; B, from the lung 
of a mouse. 



V 



Fig. 117.— Spore Formation in Bactdi/us 
of Malignant CEdema. (Fluegge.) 



Malignant CEdema. — The bacillus of malignant oedema was de- 
scribed by Koch as the cause of a fatal disease in guinea-pigs and rab- 
bits. The same bacillus was described b}^ Pasteur as " vibrion septique." 
Recently, this disease has been found also in some of the domestic mam- 
malia and in man. The bacillus resembles morphologically the bacillus 
anthraeis. 

Usually, two or three bacilli are joined end to end, and thus form 
straight or curved rods two or three times the length of one bacil- 
lus. When stained, the threads present a granular appearance, from the 
unequal distribution of the staining material. 

This bacillus is somewhat narrower than the anthrax bacillus, and 
when stained does not present such a regular, chain-like appearance. 
Sometimes the bacillus is found motile, but not always, while the anthrax 
bacillus is always devoid of this property. It multiplies by spores, but 
these appear only in the middle and at the ends. 



BACTERIOLOGICAL RESEARCHES. 



339 



This microbe is anaerobic, and can only be cultivated by exclusion 
of oxj^gen. The bacillus can only grow in the interior of agar-agar, 
gelatin, or coagulated blood-serum, if the needle-puncture on the sur- 
face of the nutrient medium is hermetically sealed. The growth of the 
bacillus is attended by the formation of gas-bubbles. 

The gas has an intensely offensive odor. Blood-serum is liquefied. 
The temperature of the blood is most favorable to the growth of the 
bacillus, and cultures develop also, but slowly, at a temperature of 
18° to 20° C. 

This bacillus is widely diffused, and can be found in almost any 
putrefying substance. The bacillus of malignant oedema possesses the 
power of peptonizing albumen. It is found in abundance in garden- 
earth and hay-dust. If a small quantity of 
either of these substances is inserted un- 
derneath the skin of a guinea-pig, death is 
produced within forty-eight hours. The 
most characteristic post-mortem appearance 
is a diffuse oedema at the point of inocula- 
tion. The oedema-fluid is a clear, reddish 
serum, in which can be found bubbles of 
gas and numerous bacilli. The spleen is 
enlarged, of a darker color than normal, 
but the other organs present no macroscopi- 
cal changes. The bacilli can be found in 
the parench} T ma-fluid of nearly all organs, 
and especially is their number great in the 
envelopes of the infected organs. Mice die 
in from sixteen to twenty hours after inocu- 
lation. Horses, sheep, and pigs can be suc- 
cessfully inoculated, while cattle are immune to the bacillus. The 
disease can be communicated from animal to animal by implantation 
of fragments of infected tissue or by inoculation with 1 or 2 drops of 
the oedema-fluid. Surface inoculation is harmless, as the bacillus will 
not multiply when exposed to atmospheric air. In man malignant 
oedema appears in the form of progressive gangrene with emphysema 
{gangrene gazeuse). Recently, the identity of this disease with malig- 
nant oedema has* been proved by inoculation experiments by Chaveau, 
Arloing, Brieger, and Ehrlich. Animals which have recovered from an 
attack of malignant oedema remain immune to this disease, but prophy- 
lactic inoculations have so far }nelded only negative results. Chaveau 
made many experiments on guinea-pigs, sheep, and horses by injecting 
the liquid contents of bullae which he found in cases of septic gangrene. 





Fig. 118— Cultures of Bacillus 
of Malignant CEdema in 
Gelatin. (Fluegge.) 



340 PRINCIPLES OF SURGERY. 

In doses of J drop in guinea-pigs and from 2 to 4 drops in horses, it 
produced death in a short time. In all cases the necropsy showed, at 
the point of injection, localized oedema and turbid serum in the perito- 
neal, pleural, and pericardial cavities. In the fluids the bacillus could 
always be demonstrated under the microscope. The disease could be 
reproduced in other animals by inoculation with the serous fluid con- 
tained in any of the serous cavities. The microbe proved less virulent 
when injected directly into the circulation. 

PYOGENIC MICROBES AS A CAUSE OF SEPSIS. 

The general symptoms which accompan}^ all suppurative affections 
represent, etiologically and clinically, a form of sepsis, which differs in its 
intensity according to the quantity of pus-microbes, or their ptomaines, 
which reach the general circulation. The slight fever which often 
attends the development of a furuncle ceases with the removal of the 
products of inflammation, while a septic or diffuse suppurative perito- 
nitis results in death in a short time from septic infection. The different 
forms of suppurative inflammation result in gangrene if the disease 
prove fatal ; the immediate cause of death is usually septic infection or 
putrid intoxication. Watson Cheyne maintains that the microbes of 
sepsis onPy grow in loco, and act by producing toxic ptomaines, or, if 
they occur in the blood, they do not make emboli. 

Yidal reported to the Academie de Medecine de Paris the results of 
his studies of the " forme septieemique pure " in puerperal fever of 
t3^phoid tj'pe without suppuration. In all of the cases in which he made 
a bacteriological examination he found the streptococcus pyogenes, and 
from this and the results of his culture and inoculation experiments he 
comes to the conclusion that it is impossible, in the present state of our 
knowledge, to distinguish between the various forms of streptococci, and 
that one and the same kind can set up any of the various forms of septic 
infection. Besser has examined 22 cases of traumatic sepsis, and found 
microbes of suppuration in every one of them. During the patient's 
life he discovered the microbe (a) in the blood in 4 of 16 cases exam- 
ined ; (b) in the pus or fluid discharge from the primary focus, in 17 of 
17 ; (c) in the urine, in 3 of 4 ; and (d) in the sputa, in 3 of 3 ; while 
after death the microorganism was present (a) in the blood, in 7 of 15 ; 
(b) in the internal organs, in 16 of 18 ; and (c) in the pus or uterine dis- 
charges, in 12 of 12. In 6 of 22 cases pus-microbes were simultane- 
ously detected side by side with masses of bacteria of many other 
species. In 3 cases, however, the streptococcus was found alone, unasso- 
ciated with an} r other microbe. Besser is of the opinion that the strep- 
tococcus of suppuration is the most frequent cause of sepsis. Smith 



CLINICAL FORMS OF SEPTICEMIA. 341 

isolated and cultivated, from 2 eases of puerperal sepsis, a streptococcus 
which, by inoculation and cultivation experiments, differed from the 
streptococcus of Fehleisen and the ordinary streptococcus of suppura- 
tion; He made a series of gelatin cultures with blood taken from the 
heart. After an interval of two or three days numerous colonies 
appeared. Rats inoculated with a pure culture died in from three to 
four days ; the same microbe was discovered in their blood. Inoculations 
were also made in the ears of rabbits, and at the end of twenty-four 
hours a circumscribed redness without tendency to diffusion was appar- 
ent, the redness disappearing in two or three days. Another series of 
cultures and inoculations was made with blood taken from the finger of 
a woman sick with puerperal fever, with similar results. 

From these considerations it becomes evident that the essential bacterial 
cause of septic semia is variable, and that the disease represents a general 
febrile condition, which is brought about by the absorption from a local 
focus of different toxins from as many different microbes. As the in- 
troduction into the circulation of the products of putrefaction is fol- 
lowed by a complexus of symptoms which closely resemble what is 
understood clinically by the term septicaemia, and as different microbes 
have been cultivated from septic patients, it would seem that this disease 
can be produced by any of the microbes which, after their introduction 
into the organism, have the capacity to produce a sufficient quantity of 
phlogistic toxins to give rise to septic intoxication. 

CLINICAL FORMS OF SEPTICEMIA. 

A clinical description of septicaemia cannot be given without a sub- 
division of the disease upon an etiological basis. Since the publication 
of Gaspard's researches it is absolutely necessary to make a distinction 
between septic intoxication and septic infection. By septic intoxication 
is understood that form of septicaemia which is caused by the absorption 
from a local focus of a ferment or the products of putrefaction, while the 
term septic infection is limited to those cases where septic microorgan- 
isms gain entrance into the circulation, and not only exercise their patho- 
genic properties in the blood, but retain their capacity of reproduction 
in the circulation and distant organs. Septic intoxication is caused by 
the absolution of a preformed ferment or toxin, which produces the 
maximum result as soon as it reaches the circulation, and the symptoms 
subside with the arrest of further supply and the elimination of the septic 
material from the circulation. Septic infection, on the other hand, occurs 
in consequence of the introduction into the circulation of living micro- 
organisms which multiply with great rapidity in the blood, — a circum- 
stance which imparts to this form of septicaemia its progressive character. 



342 PRINCIPLES OF SURGERY. 

Septic intoxication is caused either by the absorption of fibrin fer^ment or 
the products of putrefactive bacteria. 

(a) Fermentation Fever. — Fermentation fever (Bergmann), after-fever 
(Billroth), aseptic fever (Yolkmann), resorption fever, are terms used to 
designate a general febrile disturbance caused by the absorption of the 
products of aseptic tissue necrosis. This, the most simple and harmless 
of all wound complications, appears as a temporally fever soon after an 
injury or operation, and is caused \>y the absorption of aseptic phlogistic 
substances. Different aseptic inert substances, when injected into the 
circulation, are known to produce a rise in temperature. Bergmann wit- 
nessed such a reaction after iutra-venous infusion of a pl^siological solu- 
tion of salt ; Freese, after transfusion of blood of healthy animals ; and 
Bergmann, Strieker, Albert, and Billroth, after intra-venous injections of 
a considerable quantity of well-water. The same effect is produced by 
intra-venous injections of water in which fine foreign particles, as flour 
or finePy -pulverized charcoal, are suspended. Yolkmann and Genzmer 
observed a rise in temperature in patients soon after the operation was 
completed and when the wound remained aseptic throughout, and hence 
called this form of feA T er aseptic fever. These authors attribute the fever 
to the reception into the blood of dead tissue material. Bergmann 
devised the term fermentation fever upon the theory that the fever is 
caused b}^ the presence of fibrin ferment in the blood. 

Angerer and Edelberg demonstrated experimentally that this fever 
occurs after transfusion, if the blood transfused contain fibrin ferment. 
Schmiedeberg attributed the fever to the presence of another blood fer- 
ment w r hich he discovered and whicli he called "histozym." Bergmann 
and Angerer's experimental researches show that a fever which resem- 
bles the fermentation fever almost to perfection can be artificial^ pro- 
duced in animals by intra-venous injections of pancreatin, pepsin, and 
trypsin. It would appear that the albuminoid substances, which are in 
excess in the blood, undergo oxidation by the action of a ferment, and 
that the chemical changes brought about in this manner occasion rise in 
temperature, while the products of oxidation are eliminated through the 
kidneys. Riedel found, in man}^ cases of simple subcutaneous fracture, 
albumen in the urine during the first three or four days, and the urine 
alwa}'s contained brown masses, which he regarded as products of the red 
blood-corpuscles. W. Miiller found invariably, after transfusion of blood, 
a considerable increase of urates in the urine. The occurrence of 
fever after the introduction of foreign aseptic substances into the cir- 
culation can only be explained upon the supposition that they destroy 
red and white corpuscles in the blood, and that in this manner fibrin 
ferment, the cause of the fever, is generated. 



CLINICAL FORMS OF SEPTICAEMIA. 343 

Symptoms and Diagnosis. — Fermentation fever is prone to follow an 
operation or injury if antiseptic solutions are allowed to remain in the 
wound, thereby causing necrosis of the superficial tissues, or where, after 
closure of the wound, parenchymatous oozing gives rise to tension, — a 
local condition which forces the products of coagulation necrosis into 
the circulation. As not all extravasations of blood give rise to fever, 
we must take it for granted that when fever is not produced its absence 
is owing either to an absence of fibrin ferment or the existence of local 
conditions which prevent its absorption. From my own observations I 
am convinced that the amount of extravasated blood holds no relation 
whatever to the frequency of its occurrence or its intensity. A small 
extravasation under high pressure is more frequently the cause of fermen- 
tation than a large blood-clot in a location less favorable to the absorp- 
tion of fibrin ferment. Fermentation fever makes its appearance within a 
few hours after an injury or operation, and, as a rule, it is not preceded 
by a chill. The temperature rapidly reaches its maximum, which varies 
from 100° to 104° F., and remains, without much variation, in the 
vicinity of the maximum height, to drop suddenly to normal at the end 
of the first to the third day. The pulse is correspondingly increased in 
frequency during the febrile attack. The sensorium remains intact, the 
appetite is not much disturbed, and none of the subjective symptoms are 
proportionate to the severity of the febrile disturbance. Patients with 
a high temperature feel so well that, if their wounds permit it, they will 
insist in walking around and will attend to their business, contrary to the 
advice of the attending surgeon. The most important diagnostic features 
of fermentation fever are its early onset after an injury or operation, 
and its spontaneous subsidence in from one to three days. As the 
disease is caused by the introduction of phlogistic substances from a 
local focus, and propagated by intra- vascular chemical changes, it is 
uninfluenced by any form of medication. The fever subsides sponta- 
neously upon cessation of the primary cause, and with the elimination 
through the kidneys of the products of intra- vascular chemical changes. 
As the remaining forms of sepsis usually appear at a time when fermen- 
tation fever has run its course, the differential diagnosis presents no 
great difficulties. 

The treatment of fermentation fever is entirely of a prophylactic 
nature. The prophylactic measures consist in a careful haemostasis, and 
in cases where parenchymatous oozing, from the nature of a wound or 
the anatomical structure of the tissues, is to be expected, the prevention 
of the accumulation of the primary wound-secretion by efficient drainage. 
Fermentation fever must be included among the septic diseases, as the 
fibrin ferment acts as a toxic substance in the same manner as the toxines 



344 PRINCIPLES OF SURGERY. 

elaborated by septic microorganisms. Future research may yet demon- 
strate that even this, the most harmless form of septicaemia, is not an 
aseptic fever, but that it is caused by pathogenic microorganisms, either 
too few in number or not of sufficient potency to produce the graver 
forms of the disease. 

(b) Sapraemia. — This term was devised by Mathews Duncan to include 
a form of septicaemia resulting from the absorption of the products of 
putrefaction. Sapraemia is the typical form of septic intoxication, as it 
is alwaj^s caused by the introduction into the circulation of preformed 
toxines or ptomaines elaborated in dead tissues by putrefactive bacteria. 
It is closely allied to fermentation fever, as the sjanptoms are never in- 
tensified after the removal of the primary cause, but, as a rule, subside 
promptly after this has been accomplished. As sapraemia never occurs 
without putrefaction of necrosed tissue, and as putrefaction never takes 
place without infection with putrefactive bacteria, it becomes necessary 

to consider briefly the microorganisms which are 
known to cause the clinical forms of putrefaction. 

2 3 



Fig. 120. Fig. 121. 

Figs. 119, 120, and 121.— Bacillus Saprogenes 1, 2, 3. 962 : 1. (JZosenbach.) 

Bacilli of Putrefaction. — The bacilli of putrefaction exercise their 
pathogenic qualities only in dead tissue exposed to the atmospheric 
air. Clinically the} r are therefore present in the products of coagulation 
necrosis, or as a secondaiy infection in tissues destined by other micro- 
organisms. Most of them possess gasogenic properties. Rosen bach 
discovered, in different fetid secretions, three forms of bacilli which he 
designated respectively bacillus saprogenes 1, 2, 3, 

Bacillus Saprogenes 1. — A comparatively large bacillus, which mul- 
tiplies by end spores, which, however, grow only from one end of the 
bacillus. 

On nutrient agar-agar the bacillus grows in the form of an irregular 
sinuous streak, with a mucilaginous appearance. The bacilli grow 
readily also in blood-serum, and all cultures emit the odor of decom- 
posing kitchen refuse. Albumen or meat acted upon b} r a culture of this 
bacillus undergoes rapid putrefaction if exposed to atmospheric air, but 
if air is excluded the action of the microbes upon these substances is 
very slight. Cultures injected into healthy tissues and joints are 
harmless. 




CLINICAL FORMS OF SEPTICEMIA. 345 

Bacillus Saprogenes 2. — This bacillus was isolated by Rosenbach 
from fetid sweat. The rods are shorter and thinner than the preceding 
ones. 

This bacillus develops very rapidly on agar-agar, forming transparent 
drops, which become gray. The culture yields a characteristic fetid 
odor, similar to the last. Cultures of this bacillus injected into the 
knee-joint and pleural cavity of rabbits caused acute suppurative 
inflammation and death. 

Bacillus Saprogenes 3. — This bacillus was discovered by Rosenbach 
in the pus of 2 cases of osteomyelitis with septic manifestations 
complicating compound fracture. 

Cultivated on nutrient agar-agar, an ash-gray, almost liquid culture 
is developed, with a strong, characteristic odor of putrefaction. Injected 




«§|l few mm 






{am 

w 

WW 



7 








Fig. 122.— Proteus Vulgaris. 285:1. Swarming Islets. (Hauser.) 

into the knee-joint or abdomen of a rabbit, an opaque, yellowish-green 
infiltration resulted. 

Proteus Vulgaris. — This and the following species have been recentty 
described by Hauser as present in putrefying meat-infusions, and as 
being intimately connected with the process of putrefaction. As the 
name indicates, these bacteria are capable of changing their form during 
their development. The different species of proteus have been described 
as coccoid, bacteroid, spindle-shaped, and spiralinar, on account of the 
ever-changing form they assume during their growth. In proteus vul- 
garis the bacteria vary greatly in size. 

Many of the rods are actively motile, and cultivated upon nutrient 
gelatin they convert it into a turbid, grayish-white liquid. If cultivated 
in a capsule containing 5 per cent, of nutrient gelatin, a few hours after 
inoculation, the most characteristic movements of the individual bacilli 



346 



PRINCIPLES OF SURGERY. 



are observed on the surface of the gelatin, although at this early stage 
no liquefaction can be detected. The movements are not observed if 
the nutrient medium contains 10 per cent, of gelatin. Spore formation 
was never observed. Injected subcutaneous^ in small doses, no results 
were obtained ; larger doses sometimes caused circumscribed abscess at 
the point of injection. Intra-venous injection of a large dose produced 
toxic sjanptoms in rabbits and guinea-pigs, and these were not modified 
by using the filtrate of a liquefied culture, showing that the toxic sub- 
stance was held in solution. 

Proteus Mirabilis. — Rods varying greatly in length, sometimes so 
short that the} T appear like cocci, at others of considerable length. 

The rods occur singly and in zoogicea, and sometimes in tetrads, 
pairs, chains, or as short rods in twos, 
resembling bacterium termo, — in fact, 
in all conceivable transition forms. 

Cultivated on nutrient gelatin 
they form a thick, whitish hryer, in 
concentric circles, which in time lique- 
fies the medium. Similar movements 
are observed in capsule-cultivations 
as with proteus vulgaris. The patho- 
genic properties of the mirabilis are 
the same as those of vulgaris. 

Proteus Zenkeri. — Rods about 
four times as long as wide, in two, 
like bacterium termo. Cultivated on 
nutrient gelatin no liquefaction re- 
sults, but a thick, whitish-gray layer 
is formed, with sloping margins. The 
bacilli are motile, and the same phe- 
nomena are observed on the solid medium as in the other forms. Spirilli 
and spiralinar forms are seldom seen. Gelatin and blood-serum cultures 
emit no fetid odor, but meat-infusion undergoes rapid putrefaction and 
yields the usual fetid odor. The pathogenic qualities are the same as 
those of the other species of proteus. 

As the microbes of putrefaction, which have first been described, 
possess limited or no pathogenic qualities when introduced into healthy 
tissue, it is evident that their toxic effect is caused by a soluble substance 
which they produce when they find their way into dead tissue exposed to 
atmospheric air. This leads us to a consideration of the 

Ptomaines. — Ptomaine is a term used to designate certain toxic 
substances (resembling alkaloids) which are produced during the process 




Fig. 123.— Proteus Mirabilis. 285 :1. 
Swarming Islets. (Hauser.) 



CLINICAL FORMS OF SEPTICEMIA. 



347 



of putrefaction. Gautier has shown that in dead animal tissues proc- 
esses of putrefactive decomposition set in, by which certain alkaloids 
are elaborated from albuminous substances, which have been called 
ptomaines by Selmi. In the latter part of the seventeenth century 
Kircher and Leuwenhoek claimed that putrid substances contained 
minute microscopical worms, which caused the putrefaction. In 1820 
Kerner pointed out the resemblance between the symptoms of poisoning 
by sausages and by atropine. He was thus the first to raise the sus- 
picion that toxic alkaloids were formed through the decomposition of 
albumen. In 1856 Pannm showed that the inflammatory change which 
occurs in the intestinal mucous membrane of animals fed on putrid 
infusions is due to a chemical poison, which remained unaffected by 
boiling for a long time ; and his conclusion that the toxic substance 
contained in putrid fluids was of a chemical nature was confirmed by 
Weber, Hemmer, Schweninger, Stich, and Thiersch. In 1875 W. B. 




Fig. 124.— Involution Forms of Proteus Mirabiljs. 524:1. (Hauser.) 

Richardson isolated a toxic substance, which he called " septine," from 
the inflammatory transudation in the peritoneal cavity of a person that 
had died of pyaemia. With this substance he successfully infected 
animals. He also found that this substance could be made to combine 
with acids, so as to form salts, without losing its toxic qualities. Berg- 
maiin and Schmiedeberg isolated a crystalline poison from decomposing 
yeast, to which they gave the name of "sepsin." This substance, when 
injected into the subcutaneous tissue or venous circulation in animals, 
produced well-marked symptoms of septic intoxication ; the intensity of 
the symptoms were found to vary with the amount of the substance in- 
jected. Zuelzer and Sonnenschein obtained, from macerated dead bodies 
and from putrid meat-infusions, small quantities of a crj^stallizable sub- 
stance which exhibited the reactions of an alkaloid, and had a pl^sio- 
logical action like atropine, dilating the pupil, paralyzing the muscular 
fibres of the intestine, and increasing the rapidity of the pulse. In 
185T, Pasteur made the important discovery that specific microorganisms 



348 PRINCIPLES OF SURGERY. 

are the cause of the various forms of fermentation and putrefaction. 
No discovery, perhaps, attracted such universal attention as Pasteur's 
theory of fermentation. This theory was strengthened somewhat later 
by Lemaire's observation, that all fermentative changes in fluids are sus- 
pended on the addition to the fluids of phenic acid, from which he 
concluded that fermentation must be due to living organisms. Next 
came the carefully-conducted experiments of Lister, who showed that air 
is deprived of its action in causing putrefaction of organic substances 
if it is passed through a filter, or if the fluids are placed in an open vessel 
with the mouth of the vessel so arranged that dust cannot reach the 
fluid by gravitation. 

Lister's great life-work, antiseptic surgery, that has created a new 
epoch in the history of medicine and surgery, is based upon what then 
was still a theoiy, that inflammation, suppuration, and septic infection 
of wounds are caused bj T living specific microorganisms. Selmi discov- 
ered ptomaines in an exhumed body, in 1872. The ptomaines isolated 
by him were volatile alkaloids. Gautier, independently of Selmi, and 
about the same time, made the same observations, but believed that the 
toxic substances were volatile, and that in their action they resembled 
the narcotics, morphia and atropia, and were more nearly allied to the 
alkaloid extracted from poisonous mushrooms. 

Semmer gives an account of the action of septic substances as 
studied experimentally b}^ Guttmann, of Dorpat. The experiments were 
made with putrid substances, products of inflammation, septic blood, 
and cultivations of septic bacteria. These researches showed that a 
chemical poison is formed in putrefying substances, and that a certain 
quantity of such poison produces symptoms of sepsis and death in 
animals. The blood of animals killed with such putrid poisons was 
found to possess no infective qualities, and the usual putrefactive bac- 
teria were destroyed in the blood, and only appear again after the death 
of the animal. It was claimed, even at that time, that the bacteria 
elaborate the poison, as experiments made with cultures grown outside 
the bod} T produced the same effect. Another conclusion arrived at was 
that putrid substances administered subcutaneously may produce 
gangrene, phlegmonous inflammation, or eiysipelas, according to the 
stage of putrefaction, temperature, culture-soil, etc. The infective 
material was never found in the blood, but alwa} r s in the products of 
inflammation. It was clearly stated that true septicaemia is alwa} T s 
preceded by a stage of incubation, and that its contagium is destroyed 
by boiling, putrefaction, and germicides. 

Bergmann and Angerer produced a condition in animals resembling 
septicaemia, by injecting into the circulation pepsin, pancreatin, and 



CLINICAL FORMS OF SEPTICAEMIA. 349 

trypsin. When death occurred after intra- vascular injections of these 
ferments, fibrinous deposits were found in the heart and pulmonary 
vessels. These experiments were, therefore, confirmatory of the obser- 
vations previously made by Edelberg and Birck, who had shown that 
the injection of putrid substances into the circulation materially increased 
the free fibrin ferment in the circulating blood. 

Blumberg concluded, from his numerous experiments on animals, 
that the symptoms which follow an injection of putrescent material into 
the circulation are not always constant ; that, in fact, extreme prostra- 
tion, high temperature, rapid pulse and respiration are the only constant 
symptoms found. The same author also confirmed the statement that 
the blood of patients dying from putrid intoxication contained no 
microorganisms. Samuel maintains that putrid fluids, from the second 
da}^ until the eighth month of putrefaction, act differently, and divides 
their action according to this supposition into three stages : 1. Phlogo- 
genic, in which they produce only inflammation. 2. Septogenic, in which 
they produce in the living organism putrefactive processes. 3. Pyogenic, 
in which they cause only suppuration, having lost in the meantime their 
other pathogenic qualities. 

Mikulicz found that putrid fluids, according as they are free from 
bacteria or contain more or less of putrefactive microbes, will produce a 
slight inflammation, a suppurative inflammation, or a progressive phleg- 
monous inflammation. Frankel detected but few micrococci in the blood 
of septicemic patients, and observed that they greatly increased after 
death ; but, after the lapse of some further time, altogether disappeared, 
thus also confirming a fact previously known, that putrefaction destroyed 
septic microbes. These observations may tend to harmonize the dis- 
crepancy of opinion, growing out -of the different results obtained by 
different experimenters, by injections of putrid substances, as some of 
the fluids may have contained an abundance of living microorganisms, 
while others may have been rendered sterile by age, owing to advanced 
putrefactive changes. Brieger and Maas have rendered valuable service 
in the chemical isolation of ptomaines, or, as Brieger calls them, toxines, 
from putrid substances, and the results of their inoculation experiments 
established more firmly the fact of putrid intoxication by these soluble 
alkaloid substances. The number of bacteria in rabbits killed by septic 
infection is so great that death maj^ ensue from simple mechanical causes, 
while in fatal cases of sepsis in man the number is often so small that it 
seems natural to suppose that the microorganisms are capable of pro- 
ducing some poisonous substance, which destro}^ the patient before they 

have time to multiply to the extent observed in septicaemia in rabbits 
and mice. 



350 PRINCIPLES OF SURGERY. 

Rinne asserts that the chemical products of pus-microbes alone, as 
well as sterilized putrid fluids, never produce metastasis. He sterilized 
fluid cultures of the staphylococcus pyogenes aureus after filtration, and 
injected directly into the blood-vessels of rabbits as much as 4 grammes 
of this fluid, and in dogs increased the dose to 14 grammes. Many of 
the animals showed slight symptoms of septic intoxication, somnolence, 
diarrhoea, and collapse. By using still larger doses the symptoms were 
intensified and the animals died from well-marked symptoms of septic 
intoxication. Metastatic abscesses were never found in these cases. 
The same author has recently published some very interesting observa- 
tions on the immediate cause of death in rabbits inoculated with a pure 
culture of Koch-Gaffky's bacillus. The animals were inoculated at the 
base of the ear, and immediately after death the ptomaines were isolated 
from the tissues by Brieger's method. In every instance he obtained a 
substance called methylguanidin, which on chemical analysis was shown 
to consist of the formula C 2 H 7 N 3 . When this substance was injected 
into rabbits it produced symptoms of septic intoxication which 
resembled, in every particular, those produced by the injection of pure 
cultures obtained from septicemic rabbits. As methylguanidin could 
not be produced from the cadavers by the same method, Hoffa naturally 
came to the conclusion that it was a product of the bacilli, and that 
death was to be attributed to the production of this toxic substance in 
the tissues of the infected animals by the specific action of the bacilli. 
The source of methylguanidin in the body is kreatin, and the bacteria 
must possess the property of oxidation, as kreatin is transformed into 
methylguanidin only by oxidation. Brieger has isolated from human 
corpses a different set of toxic alkaloids, one of which he calls " cadav- 
erin" and the other " putrescin," which are but feeble poisons ; while 
two others, " madeleine " and " sepsin," which are produced later on in 
the decomposition, are much more powerful poisons, causing paralysis 
and death. From decomposing albuminous substances he has obtained 
many other well-defined chemical bodies, as well as some substances to 
which no names have yet been given. 

Bourget isolated several toxic bases from the viscera of a woman 
who had died of puerperal sepsis. He also obtained from the urine 
from patients suffering from the same disease similar toxic bases, which 
killed frogs and guinea-pigs, when administered by injection, showing 
that the toxic substances formed during life, and that they are elimi- 
nated through the kidneys. 

The experimental and clinical researches to which I have referred 
above show conclusively that septic intoxication is caused by the presence 
of dead tissue in the body in a state of putrefaction, from the presence 



CLINICAL FORMS OF SEPTICEMIA. 351 

of putrefactive bacilli, and that the immediate cause of the intoxication 
is the absorption of preformed ptomaines from such a local focus of 
putrefaction. 

Symptoms and Diagnosis. — Septic intoxication sufficient in severity 
to give rise to grave general disturbances is usually initiated by a chill, 
or at least b} 7 a sensation of chilliness, followed by a continued form of 
fever, the temperature rapidly increasing to 102° to 104° F., with slight 
morning remissions. The character of the pulse furnishes the most reli- 
able information in regard to the intensity of the intoxication. All 
ptomaines of putrefactive bacteria exert a depressing influence on the 
heart; hence the force and frequency of the pulse furnish important 
diagnostic and prognostic evidences. The pulse is always soft and com- 
pressible, — qualities which indicate diminished intra-vascular pressure, 
resulting from an enfeebled vis a tergo. Complete loss of appetite, 
vomiting, and diarrhoea are almost constant symptoms in grave cases. 
The tongue is usually furred, dry, and, in severe cases, presents the 
" dried-beef " appearance. The urine is scanty and heavily loaded with 
urates. Headache is often complained of in the beginning of the attack. 
Delirium, restlessness, insomnia, are symptoms which denote approach- 
ing danger. Subsultus, dilatation of pupils, clammy perspiration, livid 
appearance of visible mucous membranes, low-muttering delirium, invol- 
untary discharges, coldness of the extremities, fluttering, and feeble pulse 
precede death from septic intoxication. One of the most important 
elements in the diagnosis is the detection of a local focus of putrefaction. 
As the putrefaction always occurs in parts of the bod} r exposed to the 
atmospheric air, its existence can readily be ascertained by the sense of 
smell. The intensity of the foetor of the gases produced by the putrefac- 
tive bacteria varies greatly, but the smell is always suggestive of decom- 
posing meat or kitchen refuse. The impression is quite prevalent, not 
only among the laity, but also in the profession, that the local lesions 
which cause septicaemia always emit a fetid odor. This is a grave mis- 
take. Foetor is associatad with putrefaction, and as such is suggestive of 
sapraemia, and not true progressive sepsis. The latter may be combined 
with sapraemia, but when it occurs independently of this no bad smell 
can be detected, and yet it is the most fatal form of sepsis. In reference 
to the differential diagnosis between sapraemia, fermentation fever, and 
septic infection, it must be remembered that septic intoxication can only 
occur from putrefaction, and therefore three conditions must invariably 
be present in the etiology of this form of sepsis : 1. Dead tissue. 2. 
Infection of this dead tissue with putrefactive bacteria. 3. A sufficient 
length of time must have elapsed since the injury or operation for the 
putrefactive bacteria to produce a toxic quantity of ptomaines to cause 



352 PRINCIPLES OF SURGERY. 

sj^mptoms of intoxication. The dead tissue may be a blood-clot in a 
wound, around the fragments of a compound fracture, or in the interior 
of the uterus ; it may be tissue devitalized by a trauma, heat or cold, 
the action of chemical substances, or the action of bacteria other than 
putrefactive; or it may- be detached, retained fragments of placental 
tissue. That such dead tissue has become the seat of infection with 
putrefactive bacteria can be ascertained by the presence of foetor and 
bubbles of gas. At the temperature of the bodj T putrefaction progresses 
very rapidly ; but a differential diagnosis can generally be made without 
much difficulty, between sapraemia and fermentation fever, by the time 
which has elapsed between the injuiy or operation and the manifesta- 
tion of the first symptoms of septic intoxication. Fermentation fever 
appears within a few hours, certainty always before the end of the first 
day, while septic intoxication from putrefaction seldom begins before 
the expiration of twenty-four hours. If septic infection begin during 
this time it is not attended by any evidences of putrefaction. 

Prognosis. — Uncomplicated sapraemia proves fatal by the absorption 
of a deadly dose of ptomaines from a local depot of putrefaction, and 
the prognosis will therefore depend upon the stage of intoxication and 
the feasibility of the removal of the infected dead tissue by surgical 
treatment. If an efficient, radical treatment can be instituted at a time 
before a fatal dose of toxic substances has reached the general circula- 
tion, the prognosis is favorable. A decomposing blood-clot or detached 
fragment of a placenta can be readily removed and the field of operation 
sterilized. The prognosis in saprsemia complicating progressive gan- 
grene is always grave, as the dead tissue is increased by other microbes ; 
hence the conditions created by both kinds of microbes are of a pro- 
gressive character. 

Treatment. — The prophylactic treatment of saprsemia consists in the 
removal of dead tissue, prevention of subsequent extravasation and ac- 
cumulation of blood by careful haemostasis, — if necessaiy, by drainage, 
— and finally sterilization, b}> r antiseptic measures, of dead tissue that 
cannot be removed. Iodoformization of dead tissue is an excellent 
means of preservation. In the extra-peritoneal treatment of the stump 
after supra-vaginal extirpation of the uterus, the same object is accom- 
plished by touching the raw surface with a solution of perchloride or 
persulphate of iron or pure carbolic acid. Wounds in which dead tissue 
is unavoidably retained should always be treated b} T drainage. After 
symptoms of septic intoxication have developed early, radical treatment 
must be pursued. This treatment comprises the removal or sterilization 
of the dead tissue. A decomposing blood-clot is to be removed and the 
parts are thoroughly irrigated with a solution of corrosive sublimate, and 



CLINICAL FORMS OF SEPTICAEMIA. 353 

re -accumulation prevented by efficient drainage. In cases of gangrene 
complicated Iry putrid intoxication, where it is impossible to remove the 
infected tissues by mechanical measures, and complete disinfection with- 
out such a procedure cannot be effected, the best results are obtained by 
permanent irrigation with a saturated solution of acetate of aluminum. 
Under this treatment the soluble toxic substances are washed away as 
fast as they are formed, and sterilization of the soil for the putrefactive 
bacteria is gradually accomplished by the saturation of the dead tissue 
with this safe and efficient antiseptic solution. If a suppurating cavity 
is the seat of putrefactive changes, it becomes necessary to remove the 
nutrient medium for putrefactive bacteria by first washing out the cavity 
with a strong antiseptic solution, to be followed by the mechanical re- 
moval of dead tissue, shreds of connective tissue, dead granulations, etc., 
by means of a sharp spoon or dull curette, and subsequently by another 
antiseptic irrigation. * The surgical treatment of saprsemia will soon 
decide the fate of the patient. If a fatal dose of ptomaines has reached 
the general circulation before an effort is made to procure sterilization 
of a local depot of putrefaction the local treatment will, of course, prove 
unsuccessful in preventing a fatal result, and the disease will continue 
its relentless course uninfluenced by the treatment. If, however, the in- 
toxication has not progressed to this extent, efficient local treatment is 
followed by the most brilliant results. Within a few hours after the 
sterilization of the local focus of putrefaction the temperature falls to 
normal, the pulse becomes slower and fuller. If the tongue has been dry 
it soon becomes moist ; if the patient has been delirious consciousness 
returns, and the patient is convalescent in a few days. The results of 
the antiseptic local treatment in these cases are the strong contrast with 
the useless and often dangerous internal administration of antipyretics. 
The treatment directed toward the disinfection of the local focus of 
putrefaction removes the cause of the intoxication, while the antipyretics 
may effect a temporary reduction of the temperature, but at the same 
time, by diminishing the contractile power of the heart, only add to the 
danger by diminishing the resistance to the action of a depressing poison. 
The use of antipyretics in the treatment of saprsemia is strongly contra- 
indicated. All debilitating treatment must be carefully avoided as being 
unscientific and as adding to the existing dangers. The best results are 
obtained by such local treatment by which the further production of 
ptomaines is prevented, consequently by measures which meet the etio- 
logical indications. The debilitating effects of the ptomaines on the 
heart are met by the timely and judicious administration of stimulants. 
In urgent cases such diffusible stimulants as sulphuric ether, camphor, 
and musk can be administered with advantage subcutaneously, in order 



23 



354 PRINCIPLES OF SURGERY. 

to gain time for the action of remedies which will have a more permanent 
effect on the heart. Digitalis, strophanthus, strychnia, and atropia in 
small doses are excellent cardiac tonics and stimulants, and are indicated 
in cases where the pulse is very rapid and soft, denoting a feeble 
peripheral circulation from a weakened heart. Where life is threatened 
from syncope the patient is not allowed to assume a sitting postion, for 
fear that the increased intra-cardiac pressure might result in sudden 
death from heart-failure. 

Alcoholic stimulants are to be given in doses sufficiently large to 
improve the character of the pulse, and at sufficiently short intervals to 
maintain this effect without interruption.. Brandy or whisky, in doses 
of an ounce every two hours, diluted with water, are most to be relied 
upon, but champagne, Greek sherry, or Reich's Tokayer are excellent 
substitutes. ■ If the stomach is irritable or the symptoms are less urgent, 
concentrated liquid food, like beef-tea, milk, and eg'gnogg, must be given 
at regular intervals to assist the action of stimulants in sustaining the 
heart's action until sufficient time has been gained for the elimination of 
the ptomaines. 

(c) Progressive Septicaemia. — This is the septic infection of modern 
authors, and differs from septic intoxication in that it is caused not by 
putrefactive bacteria, but hj microbes which enter the circulation from 
some local septic focus, and which retain their capacity of reproduction 
in the blood. It is called progressive sepsis, because, only too often, 
it is not followed by any abatement of the symptoms, as the essential 
cause has passed bej^ond the reach of any local treatment, and goes on 
increasing in the blood until it destroys the patient. The intoxication 
in this form of sepsis is not only caused by ptomaines which are produced 
at the primary seat of infection, bat ptomaines are also produced in the 
blood by the microbes which it contains. 

True progressive sepsis is caused by the introduction of septic 
microorganisms into the tissues, where they multiply and, later, reach 
the blood, where mural implantation and capillary thrombosis take 
place, which directly interfere with the proper nutrition and function 
of important organs, and where the septic intoxication is caused by the 
formation of ptomaines, both in the blood and living tissues. For this 
form of sepsis Neelsen has suggested the name of " acute mycosis of 
the blood," to distinguish it from putrid intoxication, which we have 
just described, and which Neelsen calls " toxic mycosis of the blood," 
in which few or no microbes are found in the blood, and in which death 
is due exclusively to the absorption of preformed toxic substances from 
a putrefying depot. 

Causes. — Klebs discovered and described a microbe, the mikrosporon 



CLINICAL FORMS OF SEPTICEMIA. 355 

septicum, which he believed was the specific cause of septic processes, 
but recent researches seem to prove that the pus-microbes are the most 
frequent cause of progressive sepsis. The pus-microbes either reach the 
circulation directly by permeating the vessel-wall, or they enter by a 
more indirect route, through the lymphatic channels. The latter mode 
of infection gives rise to the most acute and fatal form of sepsis. In 
many cases of septic infection the presence of lymphangitis can be 
demonstrated during life, and by examination after death. A few 3 T ears 
ago Bergmann advanced the theory that in septicaemia microorganisms 
enter the colorless blood-corpuscles, and by multiplication within them 
cause their dissolution, a process during which the fibrin-generators are 
elaborated, — an occurrence ending in intra-vascular coagulation and 
capillary embolism. In Koch's septicaemia in mice such a chain of 
pathological conditions can be readily demonstrated, but in many cases 
of fatal sepsis in man the microbes found in the blood are few, no de- 
struction of leucocytes can be shown to have occurred, and extravasations 
and capillary embolism are absent ; hence death cannot be attributed to 
fibrin intoxication. In such instances we can only assume the presence 
of a soluble ptomaine which is diffused throughout ihe entire body and 
destroys life by its toxic properties. The formation of pus at the primary 
seat of infection is not necessary in the causation of septicaemia by pus- 
microbes. Septic infection is as liable to take place from wounds that 
do not suppurate as from suppurating wounds. Why a wound infected 
with pus-microbes should give rise to progressive sepsis in one individual, 
and suppuration or suppuration and pyaemia in another, does not admit 
of a satisfactory explanation at the present time. 

Rinne has shown that diminution of the absorptive capacity of the 
tissues at the seat of infection plays an important part in the develop- 
ment of septic processes. If the pus-microbes are rapidly absorbed, 
destroyed in the blood, or removed by elimination, septic inflammation 
is prevented. If, on the other hand, the local conditions are such that 
the microbes remain in the tissues, and b}^ their rapid multiplication 
produce a large amount of soluble toxines, which, when the}^ reach the 
blood, not only produce intoxication, but prepare the blood and tissues 
for the localization and reproduction of the microbes at points distant 
from the primary seat of the infection, the pathogenic effect of the 
microbes on the tissues at the primary seat of infection diminishes their 
power of resistance, and the microbes either enter the blood-vessels 
directly or through the lymphatics. Experimentally it has been shown 
that if a large quantity of pus-microbes is introduced into the peritoneal 
cavity, or directly into the circulation, death results from sepsis before 
a sufficient length of time has elapsed for the pus-microbes to produce 



356 PRINCIPLES OF SURGERY. 

the histological changes which are necessary for the production of pus. 
These experiments are strongly suggestive of the fact that, in man, infec- 
tion with pus-microbes causes progressive sepsis, if a large quantity of 
pus-microbes is introduced into tissues debilitated by a trauma, antecedent 
pathological conditions, or the action of preformed ptomaines. Under 
such circumstances the pus-microbes are reproduced with great rapidity 
at the primary focus of infection, enter the circulation before suppu- 
ration has had time to develop, and produce a complexus of symptoms 
and a series of pathological changes characteristic of progressive 
sepsis. 

Symptoms and Diagnosis. — The most typical clinical picture of 
progressive sepsis is produced in cases of septic peritonitis, dissection 
wounds, puerperal septicaemia, and acute multiple osteomyelitis. In septic 
peritonitis, after laparotomy or penetrating wounds of the abdomen, the 
septic inflammation, as a rule, develops within the first forty-eight hours, 
and with it the characteristic symptoms of septicaemia appear. In 
puerperal sepsis and the gravest form of acute suppurative osteomyelitis, 
the septic symptoms often overshadow the primary disease to such an 
extent that this is entirely overlooked. Dissection wounds often prove 
fatal from septic infection, which spreads from the wound along the 
course of the lymphatic vessels, and finally becomes general through the 
medium of the circulation. Septic infection from an accidental or 
operative wound can take place within twenty-four hours, and seldom 
occurs later than the third or fourth day, unless the infection has taken 
place after the first dressing. Like all other acute infectious processes, 
septicaemia is ushered in by a more or less pronounced chill, or at least 
a subjective sensation of chilliness, which may be repeated during the 
first twenty-four hours. The chill is never so pronounced as in pyaemia, 
and does not return with the same regularity and intensity as in that 
affection. The chill announces the termination of the period of incuba- 
tion, and is promptly followed by symptoms of reaction which, in their 
severity, are proportionate to the intensity and gravity of the attack. 
One of the most prominent features of the disease is a profound pros- 
tration, which majr be well marked a few hours after the beginning of 
the attack. If septicaemia follow an operation, or a severe accident, it 
is sometimes almost impossible to decide whether the pronounced loss 
of strength should be attributed to shock, the use of an anaesthetic, or 
the beginning of an attack of septicaemia. One of the most delusive 
S3^mptoms is the utter indifference of the patient, not only as to his own 
grave condition, but to all of his surroundings. This apathy is a char- 
acteristic symptom of profound septic intoxication. The patient com- 
plains of no pain, assures the physician and friends that he is feeling 



CLINICAL FORMS OF SEPTICEMIA. 357 

well, shows absolutely no anxiety concerning his own fate, and does 
not comprehend the anxiety of those around him. Drowsiness, border- 
ing almost on stupor, is frequently observed. The face presents a 
pale or ashy-gray color, and in advanced cases it presents a 3'ellowish, 
icteric tint, but the sclerotica alwa^ys retains its white color. In the 
beginning of the attack the pulse ranges between 80 and 90, but becomes 
rapid, small, and compressible as the intoxication and capillary obstruc- 
tion progress. The character of the pulse is of great diagnostic and 
prognostic importance. If the pulse within a short time reach a fre- 
quency of 140, and imparts the sensation as though the arteiy were only 
half filled with blood, it is a symptom which forebodes immediate danger. 
The temperature is variable. A subnormal temperature, with a rapid, 
feeble pulse, indicates a grave and probably fatal form of sepsis. If the 
temperature is at first only slightly increased, but gradually rises to 103° 
or 104° F., it denotes progressive sepsis. A high temperature and a 
firm pulse, not exceeding 120 beats to the minute, are indications of less 
serious import than a low temperature with a rapid, feeble pulse. The 
eyes are sunken, often suffused with an abundant secretion from the 
conjunctiva. The features present a stolid appearance, without any 
expression of intelligence. Capillary oozing at the primary seat of 
infection is a common occurrence, and capillary haemorrhage underneath 
the skin and visible mucous membranes is frequently observed. Vom- 
iting and diarrhoea are often present from the beginning, and in rapidly 
fatal cases remain as persistent S3^mptoms, in spite of measures that may 
be employed to subdue them. The discharges from the bowels are often 
stained with blood. The urine, as a rule, is scanty and loaded with 
urates. 

Billroth places great importance upon the appearance of the tongue. 
The tongue is always coated ; in grave cases it is pointed at the tip, its 
margins are red, while the dorsal surface is dry and covered with a dry, 
often almost black, crust. Return of moisture is always a favorable omen. 
Great thirst and complete loss of appetite are always present. Delirium 
is a frequent, but not a constant, symptom. If the case progress to a 
fatal termination, the pulse becomes more and more frequent, respira- 
tions become shallow and labored, the face presents a c} r anotic hue, the 
surface is bathed with a clammy perspiration, the extremities become 
cold, and death finally is caused from heart-failure. In the differential 
diagnosis it is important to remember fermentation fever, septic intoxi- 
cation, typhoid fever, internal sepsis, and acute multiple suppurative 
osteon^elitis. Progressive septicaemia alwa} T s has a stage of incubation ; 
that is, a certain length of time intervenes between the time infection 
occurred and the appearance of the disease. This period of incubation 



358 PRINCIPLES OF SURGERY. 

may terminate at the end of a few hours and it may be prolonged to 
four clays, according to the number of pus-microbes introduced and the 
anatomical structure and physiological properties of the tissues primarily 
infected. Fermentation fever follows an injury or operation within a few 
hours, and never occurs after the expiration of twenty-four hours. In 
fermentation fever the maximum symptoms appear at once, and the force 
of the pulse and strength of the patient remain unimpaired. Fermenta- 
tion fever seldom lasts for more than one or two days, while in progres- 
sive sepsis the symptoms become aggravated as the infection increases. 
In putrid intoxication the maximum symptoms are produced by the in- 
troduction into the blood of preformed soluble toxic substances from a 
depot of putrefaction. Evidences of putrefaction in an}^ part of the 
body would speak in favor of septic intoxication, while, if septic infec- 
tion exist at the same time, it must be regarded not in the light of a 
cause, but as a complication. Typhoid fever is preceded by a well- 
marked prodromal stage which is absent in septic infection. The erup- 
tion in t} T phoid fever is characteristic, while the eruption which is 
sometimes seen in progressive sepsis closely resembles the rash of scar- 
latina, and is caused bjr the presence of pus-microbes in the superficial 
lymphatic vessels. Internal sepsis is usually preceded by a septic phar- 
yngitis, and frequently attended by ulcerative endocarditis. Acute mul- 
tiple osteomj^elitis, the cause of fatal septic infection, can be recognized 
by searching for points of tenderness in the localities attacked most fre- 
quently by this disease. The final diagnosis of septic infection must be 
based upon the existence of an infection-atrium, through which pus- 
microbes have entered the tissues, and from which they have reached the 
general circulation. 

Prognosis. — The prognosis of progressive septicaemia is always 
grave. In cases where pus-microbes exist in large numbers at the pri- 
mary seat of infection, and reach the general circulation with great 
rapidity, and meet with conditions favorable for their reproduction, 
death is inevitable in spite of the most energetic local and general treat- 
ment. The prognosis is more favorable if infection has taken place from 
a locality amenable to thorough local disinfection, if this is practiced 
upon the first appearance of symptoms, as this treatment prevents fur- 
ther ingress of pus-microbes into the circulation. The existence of mul- 
tiple points of metastatic inflammation renders a recovery improbable. 
Delirium, rapid and feeble pulse, subnormal temperature, dry tongue, 
persistent vomiting and diarrhoea are all unfavorable symptoms from a 
prognostic stand-point. Capillary haemorrhages distant from the primary 
infection-atrium are infallible indications of progressive sepsis, and 
their existence warrants a most unfavorable prognosis. Progressive 



CLINICAL FORMS OF SEPTICAEMIA. 359 

sepsis may cause death in twelve hours, and in fatal cases life is seldom 
prolonged for more than one week. 

Pathology and Morbid Anatomy. — In rapidly-fatal cases of progres- 
sive septic infection, the absence of gross macroscopical pathological 
changes is a characteristic feature of this disease. In such instances 
even the most careful search for tangible lesions will result negatively. 
Cloudy swelling of the parenchyma of internal organs indicates the 
existence of coagulation necrosis, caused by the action of the ptomaines 
of the pus-microbes. Pas-microbes have been frequently found in 
septic blood. Hemorrhagic extravasations into organs, and more par- 
ticularly underneath serous and mucous membranes and the skin, are 
frequently present. The blood presents almost a black color, and shows 
little or no tendency to coagulate. The lymphatics interposed between 
the primary seat of infection and the blood-vessels are frequently found 
in a state of septic inflammation. The wound through which infection 
has taken place may present but slight or no gross anatomical changes. 
The spleen is enlarged and the pulpa softened to the consistency of a 
blood-clot. Thrombosis and embolism are absent. Under the micro- 
scope the capillary vessels everywhere present all the evidences of a 
septic inflammation. The soluble ptomaines in the blood produce coagu- 
lation necrosis of the intima, which determines mural implantation of 
the pus-microbes and the colorless corpuscles and results in capillary 
hyperemia and congestion. In some places alteration of the capillary 
wall has taken place to such an extent as to give rise to rhexis. The 
most important microscopical changes in the tissues and organs, in 
patients who have died of sepsis, are the pathological conditions within 
and in the immediate vicinity of capillary vessels that indicate the exist- 
ence of multiple foci of metastatic inflammation, which characterize 
clinically and pathologically progressive sepsis. If life is prolonged for 
a sufficient length of time, these foci become the centre of a suppura- 
tive inflammation. Slight effusions into the large serous cavities are 
frequently found. 

Treatment. — The antiseptic measures which have been described in 
the treatment of wounds are the best and onty known means of effective 
prophylaxis against septic infection. Any method or methods of treat- 
ment which can be relied upon in the prevention of suppuration will 
be found efficient in preventing septic infection. As retention of 
wound-secretion is one of the important etiological conditions in the 
causation of septic infection in wounds that are not completely aseptic, 
drainage should be employed in all cases where an accumulation of the 
primary wound-secretion is to be feared. As septic infection is just as 
liable to occur through a small as a large wqund, the most insignificant 



360 PRINCIPLES OF SURGERY. 

injurj' should be treated upon the strictest and most pedantic antiseptic 
precautions. If, in spite of the greatest care, s3'mptoms of septic 
infection appear after an injury or operation, no time should be lost by 
the useless administration of antipyretics, in the vain hope that by 
reducing the temperature the condition of the patient will be improved, 
but the first and essential object of treatment should be to remove the 
cause of the fever by resorting to secondary disinfection. All sutures 
must be removed and eveiy portion of the wound rendered accessible to 
local treatment. Extravasated blood and necrosed shreds of tissue 
must be removed, when the wound is to be irrigated with a l-to-1000 solu- 
tion of corrosive sublimate, after which it is dried and the whole surface 
brushed with a 10-per-cent. solution of chloride of zinc. After another 
irrigation and after dicing the surface again, a thin film of iodoform is 
applied, and then the wound is tamponed with iodoform gauze and 
dressed antiseptically. Such a wound should never be re-sutured until 
the local and general symptoms indicate that it has been rendered 
completely aseptic. If this secondaiy disinfection prove unsuccessful, 
recourse should be had to permanent irrigation with a saturated solution 
of acetate of aluminum. Secondary disinfection of the peritoneal cavity, 
in cases of septic peritonitis after laparotonry, has so far not proved 
veiy satisfactory, but as it is the only recourse in dealing with such 
desperate cases, that without it would surely run a fatal course in a 
short time, it should never be neglected. A number of the sutures 
near the lower angle of the wound are removed with blunt instruments, 
the margins of the wound are separated, and the abdominal cavitj' is 
flushed with warm salicylated water until the fluid returns perfectly 
clear. The end of the rubber tube attached to the irrigator must be 
inserted in such a manner that the stream will reach the most depend- 
ent portions of the abdominal cavity; hence it is inserted into the deep- 
est portion of the pelvis, and when this portion of the abdominal cavity 
has been thoroughly washed out the lumbar regions are dealt with in 
a similar manner. After the irrigation has been completed, the patient 
is turned upon the face, so as to permit the escape of fluid by gravita- 
tion. A large glass drain is then inserted and its opening closed with 
salic3^1ated cotton, after which the antiseptic dressing is applied in such 
a manner that the end of the tube remains accessible to the removal of 
fluid by aspiration as often as circumstances may require. In progres- 
sive sepsis, following in the course of progressive gangrene of a limb, 
amputation will become necessaiy if secondaiy disinfection and perma- 
nent irrigation have proved of no avail in arresting the septic infection. 
The general treatment of septic infection is the same as has been advised 
in cases of septic intoxication. 



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INTESTINAL SEPSIS. 361 

The general treatment of sepsis consists in the employment of 
stimulants, notably alcohol and strychnia, not in measured doses, but in 
quantities which will produce the desired result. 

INTESTINAL SEPSIS. 

The subject of intestinal sepsis, in connection with the bacillus coli 
communis, has received a good deal of attention, during the last two or 
three years, on the part of bacteriologists, physicians, and surgeons. 
Intestinal infection ma} T be limited to the absorption of the toxins of 
pathogenic bacteria, when it is called intestinal toxaemia, enterosepsis 
(Billroth), enteritis septica (Gussenbauer), or it may be of a more dan- 
gerous character when the bacteria enter the general circulation from 
the intestinal mucous surface. Karlinski fed animals with milk infected 
with staphylococcus aureus. Among forty-eight experiments he found 
six times general infection with swelling and redness of the intestinal 
mucosa, while the faeces and the blood both showed the same cocci. Five 
times lie found suppurative parotitis without intestinal lesions; seven- 
teen times, acute and fatal diarrhoea; eight times, general infection with 
metastatic abscess. Aside from these experiments, there are numerous 
other observations, all tending to show that the most common microbe 
of the intestinal canal, the bacillus coli communis, may enter the general 
circulation and, becoming localized in distant parts, cause suppuration. 
In this way are to be explained the abscesses in the liver which accom- 
pany or follow dj^sentery, and in which living microbes have been 
described by Kartulis, Osier, and others. Constipation is not an essen- 
tial condition in the production of intestinal toxaemia and sepsis, as, in 
some cases, for reasons which at present cannot be explained, these con- 
ditions are associated with diarrhoea. 



CHAPTER XIV. 

Pyaemia. 

Pyaemia, or pyohaemia, is a general disease caused by the entrance 
into the circulation of pus or some of its component parts, characterized 
by recurring chills, an intermittent form of fever, and the occurrence 
of metastatic abscesses. Although this disease was known a long time 
before Piorry applied to it the name it still bears, its intimate relation- 
ship to suppurative processes was first pointed out by this surgeon. 
Piorry maintained that, as the name implies, p} r aemia is caused by the 
entrance of pus into the blood. Yirchow, on the other hand, contended 
that no pus is found in the blood of pysemic patients, and that the sec- 
ondary or metastatic abscesses are not true abscesses resulting from the 
accumulation of pus derived from the blood, but that they are the result 
of embolic processes, puriform softening, inflammation, and suppuration 
around the blocked vessels. Recent bacteriological investigations have 
shown that Pioriy's views are so far correct in that pus is produced 
within blood-vessels by the entrance of pus-microbes into the circula- 
tion. As a wound complication pyaemia can only occur after suppura- 
tion has taken place in a wound, and, as a complication of non-traumatic 
lesions, it can only develop in the course of suppurative affections. The 
great prevalence of p3 7 aemia in overcrowded and badly-ventilated hos- 
pitals, during the time before the antiseptic treatment of wounds came 
into use, gave rise to a general belief that the disease was due to a spe- 
cific cause, and ever since bacteriology became a science diligent search 
has been made to discover the specific microbe. Since the discovery of 
the microbes of suppuration, new light has been shed upon the etiology 
and pathology of this disease. Bacteriological examinations of pyaemic 
products have shown that one or more kinds of pus-microbes are always 
present, thus establishing the direct relationship which exists between a 
suppurating process in some part of the bocty and the development of 
metastatic or p} r aemic abscesses. Clinical experience has only corrobo- 
rated the scientific investigations of this subject, inasmuch as it has 
shown that the frequency of pyaemia has been diminished in proportion 
to the lesser frequency of suppurative inflammation under the antiseptic 
treatment of wounds and suppurating lesions. We are justified, upon 
the basis of well-established facts, in claiming that pyaemia is not a 

(362) 



BACTERIOLOGICAL AND EXPERIMENTAL RESEARCHES. 363 

disease per se 1 but that its occurrence depends upon an extension of a 
suppurative process from the primary seat of infection, and suppuration 
in distant organs by the transportation of emboli infected with pus- 
microbes through the systemic circulation. The distant, or metastatic, 
abscesses contain the same microbes which are found in the wound- 
secretions, or in the abscess from which the general purulent infection 
took place. Experiments have shown that a culture of pus-microbes 
from a furuncle may produce p3 7 aemia in animals, and that the microbes 
cultivated from a pyaemic abscess, when injected under the skin of an ani- 
mal, may cause only a localized suppurative inflammation without any 
general symptoms. 

BACTERIOLOGICAL AND EXPERIMENTAL RESEARCHES. 

While the direct relationship existing between suppuration and py- 
aemia was well understood clinically for a long time, it was left for Klebs 
to demonstrate for the first time the direct connection of the pj^aemic 
processes with the presence of specific microbes. In his researches into 
the nature of this disease during the Franco-Prussian war in 1870, he 
discovered in the pyaemic products certain microorganisms which he 
called micrococci of pyaemia. He found that these microbes always 
arranged themselves in the form of colonies or groups which he termed 
zoogloea. He found this microbe invariably present, notably at the pri- 
mary seat of infection, but also in the most distant organs, — wherever, 
indeed, pathological changes occurred during the course of the disease. 
Pasteur, in studying the puerperal form of pj^aemia, discovered a chain 
coccus which undoubtedly was identical with the streptococcus pyogenes, 
but which he called microbe en chapelet. Hueter and Vogt found a 
microorganism in pyaemic products which the}' include among the mo- 
nads. Burdon-Sanderson supposed that he had discovered the essential 
microbic cause of pyaemia in the shape of a " dumb-bell shaped germ" 
which in all probability was a staphylococcus. 

Schuller examined the contents of metastatic joint affections in 12 
cases of puerperal pyaemia, and invariably found pus-microbes. Rosen- 
bach investigated 6 cases of t3 7 pical pyaemia with a view to determine 
the nature of the microbes present in the pyaemic products. He found 
the streptococcus pyogenes present in the blood, and metastatic deposits 
in 5 of them ; in 2 of these cases staphylococci were also present, 
although fewer in number. In only 1 of them he found staphylococci 
alone, and this case recovered. Pawlowsky made a bacteriological ex- 
amination of the pus of metastatic abscesses in 5 cases of pyaemia. In 
4 cases he found the staphylococcus pyogenes aureus, and in the fifth 
case, which was remarkable for the extent of the joint complications, he 



364 PRINCIPLES OF SURGERY. 

found the streptococcus pyogenes. He believes that the staphylococcus 
pyogenes aureus is the usual cause of pyaemia, and especially of that 
form characterized by multiple abscesses in the internal organs. Large 
cultures of this coccus suspended in water and injected subcutaneously 
in rabbits caused death, and at the necropsy multiple abscesses were 
found. He maintains that p} T aemia in man occurs when disturbances in 
the circulation are present, so that floating cocci find favorable points for 
localization within the blood-vessels. He created such disturbances 
artificial^ in animals by making intra-venous injections of cinnabar, 
with the result that the granular material determined localization of the 
microbes which were introduced into the circulation. 

Besser examined bacteriologically blood, pus, and parencl^matous 
fluid from organs in 23 cases of pyaemia. In 8 cases the staph} T lococci 
albi and aurei were found ; in 14, streptococci ; and in 1, streptococci and 
staphylococci simultaneous^. The microbes were discovered during the 
patient's life in pus in every one of 20 cases examined ; in blood, in 11 
of 12; and in parencl^matous serum, in 1. After death, in pus, in 17 
of It ; in blood, 4 of 9 ; and in organs, 9 of 14. Besser's predecessors 
described 23 additional cases of p3 r aemia, in 14 of which staphylococci 
were found ; in T, streptococci. Total, 46 cases : in 22, staphylococci ; in 
21, streptococci ; in 3, both. Besser was unable to detect the slightest 
morphological or pathogenic difference between the microbes of suppu- 
ration and those of pyaemia. 

Okinschitz made the relationship which exists between the pus- 
microbes and pyaemia the subject of bacteriological investigation. He 
found that pyaemic blood invariably contained either the streptococcus 
pyogenes or the staphylococcus pyogenes aureus, demonstrated by 
cultivation and ordinary microscopical examination. As the haemic 
microbes seldom show any signs of fission, as compared with the bacteria 
at the primar}^ focus, it is reasonable to infer that reproduction takes 
place mainly in the pus, and not in the blood ; hence the great impor- 
tance of thorough disinfection and destruction of primary foci. The 
number of microbes in the circulating blood bears a direct relation to 
the gravit}^ of the disease. If they are abundant, even in the absence 
of metastases in internal organs, the prognosis is grave, and if scanty, 
even if metastatic foci are present, the prospects of a favorable termi- 
nation are better. 

Pyaemia in Rabbits. — Koch produced pj^aemia artificial^ in rabbits 
by injecting putrid fluids. A piece of a mouse's skin, about a square 
centimetre in size, was macerated for two daj T s in 30 grammes of dis- 
tilled water, and a S3^ringeful of this fluid was injected subcutaneously 
into the back of a rabbit. Two days the animal remained apparently 



BACTERIOLOGICAL AND EXPERIMENTAL RESEARCHES. 



365 



well, then it began to eat less, became gradually weaker, and died one 
hundred and five hours after the injection. An extensive subcutaneous 
abscess was found at the seat of injection. In the abdominal wall the 
yellowish infiltration extended in parts through the muscles and even to 
the peritoneum. The peritoneal surface presented evidences of inflam- 
mation. The intestines were adherent, and the peritoneal cavity con- 
tained a small quantity of turbid fluid. The 
liver showed on section gray, wedge-shaped 
patches. In the lungs infarcts the size of a pea 
were found. A syringeful of blood taken from 
the heart of this animal was now injected un- 
der the skin of the back of a second rabbit. 
The second animal died in forty hours, and at 
the necropsy nearly the same pathological con- 
ditions were found, only that the peritonitis 
was less advanced. Further experiments 
showed that y 1 ^ drop of pysemic blood proved 
fatal in rabbits in one hundred and twenty-five 
hours. All subsequent experiments proved 
that the less the quantity of blood injected the 
longer the time which elapsed before death 
occurred, but where the quantity was reduced 
to the one-thousandth part of a drop no result 
followed. On microscopic examination cocci 



were found in great numbers everywhere 



*«.o 



throughout the body, and more especially in 
the parts which had undergone alterations 
visible to the naked eye. 

The description of the microbe found cor- 
responds with the staphylococcus. The rela- 
tion of the microbes to the blood-vessels could 
be seen best in the renal capillaries (Fig. 125). 
In the interior of the vessel, at C, is a dense 
deposit of micrococci adherent to the wall, and 
inclosing in its substance a number of red blood-corpuscles. The capillary 
stasis is either due to the power of the microbes of causing the red blood- 
corpuscles, to which they adhere, to stick together, or their property of pro- 
ducing in their immediate vicinity coagulation of the blood, and thus cause 
thrombosis. The microbes were found so arranged that they inclosed 
red blood-corpuscles in the capillary vessels of all the organs examined, 



Fig. r,25— Vessel, from the 
Cortex of the Kidney 
of a Pyemic Rabbit. 
X700." (Koch.)* 

A, nuclei of the vascular wall ; B, 
email group of micrococci between blood- 
corpuscles ; C, dense masses of micro- 
cocci adherent to the wall and inclosing 
blood-corpuscles; D, pairs of micrococci 
at the border of the large mass. 



* Copied from "Traumatic Infective Diseases," by permission of the New Sydenham 
Society, London. 



366 PRINCIPLES OF SURGERY. 

as, for example, in the spleen and in the lungs. Koch believes that the 
large metastatic deposits in the liver and in the lungs do not arise by 
gradual growth of a mass of micrococci, as in Fig. 125, but by the arrest 
of large groups and of the clots associated with them ; in other words, 
by true embolism. In the metastatic deposits an extensive development 
of micrococci occurs, and these are not confined to the vessels, but 
invade the neighboring tissues. In the peritoneal cavity the micrococci 
were not found in large masses, but isolated, in pairs or in small 
groups. 

In the vicinity of the abscess he detected the microbes in the walls 
of veins, and their passage through these into the interior of the vessels 
could be readily discerned in many places. As Koch has pointed out, 
the microbe of pyaemia in rabbits, which is a pus-microbe, when brought 
in contact with the red blood-corpuscles, increases their viscosity and 
they form larger or small coagula in the blood. They can thus no 
longer pass through the minute capillary net-work, but are arrested in 
the smaller vessels. From the point of infection fresh micrococci pass 
constantly into the blood, and also individual micrococci will become 
detached from these small thrombi and emboli, and mix with the blood- 
stream. As the microbes are constant^ being deposited by mural im- 
plantation, their number in the circulating blood always remains relatively 
small. Klein described a micrococcus of pyaemia in mice. Certain 
cocci which were present in pork proved fatal to mice in about a week, 
producing both purulent inflammation at the point of injection and 
metastatic abscesses in the lungs. Inoculations in the same species of 
animal with pyaemic products reproduced the disease in a typical manner. 
Pawlowsk}^ found that hy simultaneous injection of sterilized cinnabar, 
and of cultivation of staplylococcus p} T ogenes aureus into the circula- 
tion, he produced abscesses in various organs — in fact, the typical picture 
of pyaemia. The presence of particles of foreign bodies rendered 
material aid in the development of metastatic abscesses, as the mere 
arrest of pus-microbes in the circulation without them, as a rule, was 
not found sufficient of itself to lead to the production of true pyaemia. 
In rabbits, even, the introduction of a large quantity of a culture of 
pus-microbes into the circulation did not produce pyaenria. Twenty-four 
hours after the injection he found the microbes in large numbers in the 
pulmonaiy and other capillaries, but after forty-eight hours tliey had all 
disappeared from the blood. If the cocci are incorporated in, or are 
attached to, an embolus, this latter, by producing alterations in the 
endothelia of the blood-vessels at the point of impaction, creates a locus 
minoris resistentide favorable to the growth of the microbes. In the 
experiments of Pawlowsky, the particles of cinnabar acted upon the 



ETIOLOGY. 



367 



endothelial lining of the capillary vessels in the same manner as the 
fragments of a thrombus, by impairing the local nutrition of the tissues 
with which they were brought into contact. 

ETIOLOGY. 

If pyaemia can be artificially produced in rabbits, mice, and guinea* 
pigs with pus or with a pure cultivation of the same with or without 
the presence of foreign bodies, the same local conditions are first pro- 
duced at the point of inoculation which invariably precede the develop- 
ment of p3'8emia in man. Some of the veins at the seat of primary in- 
fection are invaded by pus-microbes, and become blocked by a thrombus ; 
this thrombus undergoes puriform softening ; small fragments contain- 
ing pus-microbes become detached and are washed away and enter the 
general circulation as emboli, which, when they become arrested, 
establish independent centres of suppuration. In 
such cases the same microbes can be found in the 
wound, in the blood, in the tissues around the 
abscess, and in all distant pyaemic products. 
Although the streptococcus p3 7 ogenes has been 
found most frequently in the pus at the primary 
seat of infection and in the metastatic abscesses 
of pyaemic patients, there can be but little doubt 
that any of the pus-microbes, when present in 
sufficient quantity in the blood, can produce the 
disease. The occurrence of pyaemia from suppu- 
rating wounds or abscesses does not depend so much 
upon the kind of pus-mic7*obes which have caused 
the primary suppuration as upon surrounding 

circumstances. The location and anatomical structure of the tissues in 
which the primary infection has taken place exert an important influ- 
ence in the production of the disease. 

It is an exceedingly familiar clinical fact that suppurative inflam- 
mation of the medullary tissue in bone is frequentl}' the cause of pyaemia. 
Acute suppurative osteomyelitis without direct infection through a 
wound is alwnys due to intra-vascular infection, — localization of pus- 
microbes in the capillary vessels of the medullary tissue. The microbes 
come first in contact with the endothelial cells when mural implantation 
has taken place, and the coagulation necrosis which follows leads to 
thrombosis. The products of the intra-vascular coagulation necrosis 
furnish a most favorable nutrient substance for the growth and multipli- 
cation of the pus-microbes ; consequently the area of intra-vascular in- 
fection is rapidly increased. The growth of the thrombus in a proximal 




Fig. 126.— Suppurating 
Thrombus in Vein. 
(Tillmanns. ) 



368 PRINCIPLES OF SURGERY. 

direction soon leads to extensive thrombo-phlebitis, and, as softening of 
the thrombus takes place, to embolism and metastatic suppuration. 
Pyaemia following a suppurative inflammation in a wound, or in the 
course of a phlegmonous inflammation of the connective tissue, is the 
result of an infection with pus-microbes which penetrate the veins from 
without. The pus-microbes, coming first in contact with the outer coats 
of the veins, give rise to phlebitis, which progresses from without in- 
ward, and which is followed by thrombosis as soon as the intima is 
reached. The intra-vascular dissemination of the pus-microbes then 
takes place in the same manner as in cases of primary thrombo-phlebitis. 
Ordinary pyogenic microbes may and do cause pysemia, if they enter the 
blood incorporated in 1 or attached to, fragments of an infected blood-clot, 
or other solid materials, which, after they have become impacted in blood- 
vessels as emboli, prepare the soil in distant organs for their localization 
and reproduction. 

The importance of thrombosis and embolism as essential factors in 
the causation of p3'semia has been clearly established lty clinical obser- 
vation and experimental research. Emboli maj^ originate in the Em- 
phatic vessels when these are the seat of invasion by pyogenic microbes, 
which, however, is very seldom the case. In chronic pyaemia, in which 
multiple metastatic abscesses are formed, embolism takes no essential 
part in the process ; the microbes enter the blood-current without such a 
vehicle, and are brought in direct contact by mural implantation with 
the interior lining of vessels weakened by injury or other local and 
general debilitating influences. Experimental research has shown con- 
clusivety that the mere introduction of pus-microbes into the circulation 
is not necessarily, or even usually, followed by pyaemia, and their acci- 
dental entrance in the course of a suppurative inflammation is not always 
followed by serious consequences. There can be no doubt that some pus- 
microbes reach the circulation in nearly every case of suppuration, but 
their pathogenic action is prevented, or neutralized, by an adequate resist- 
ance on the part of the tissues with which they are brought in contact and 
their rapid elimination through healthy excretory organs. A limited 
number of pus-microbes injected into the circulation of a healthy animal, 
or accidentally introduced into the blood of an otherwise healthy person, 
are effectively disposed of by the white blood-corpuscles. If, however, 
the same number of microbes are present in combination with fragments 
of a blood-clot, the infected foreign particles produce such nutritive 
changes in the tissues surrounding them as to transform them into a 
favorable soil for the pathogenic action of the microbes. The same 
happens if free pus-microbes localize in a part the vitality of which 
has been previously diminished by trauma or antecedent pathological 



ETIOLOGY. 369 

changes, which constitutes a locus minoris resistentise for the growth and 
multiplication of the pus-microbes. Pysemia, therefore, must be looked 
upon rather as a serious and fatal complication of suppurative lesions 
than an independent specific disease. The immediate causes of pyaemia 
are the formation of an infected thrombus at the primary seat of infec- 
tion and disintegration of this thrombus to such an extent that frag- 
ments become detached and are conveyed by the blood-current to distant 
organs, where they are arrested in the smaller arteries as emboli. 

Thrombosis. — A thrombus is an intra-vascular blood-clot locally 
formed within the heart or a blood-vessel, and the process by which it is 
formed is called " thrombosis." A thrombus is called venous if it occur 
in a vein, arterial if it form in an artery. A red thrombus is produced 
if the blood coagulate in its entirety, while a white thrombus is com- 
posed of fibrin exclusively or the fibrin and the colorless and third cor- 
puscles of the blood. A mural thrombus is a thrombus which is attached 
to the inner surface of a vessel-wall without occluding the entire lumen 
of the vessel. Notwithstanding the numerous and ingenious experi- 
ments which have been made for the purpose of ascertaining the imme- 
diate cause of intra-vascular coagulation of the blood, this subject awaits 
a more satisfactory explanation than can be given at the present time. 
Richardson, Bruecke, and Lister have shown that the mere mechanical 
interruption to the flow of blood in a vessel is not a sufficient cause of 
coagulation. Blood has been kept in a fluid condition in a blood-vessel 
between two ligatures for an indefinite period of time in the living 
tissues. 

Virchow, Cohnheim, Baumgarten, and Zahn maintain that the color- 
less corpuscles are in the closest manner related to thrombus formation. 
Zahn, from observations on the living mesentery of the frog, found that 
when the wall of a vessel was injured the colorless corpuscles accumu- 
late around the injured part, constituting what he calls a white throm- 
bus. The corpuscles subsequently, in great part, disintegrate and give 
rise to a granular accumulation, which, by its action upon the fibrinogen 
of the blood, causes a precipitation of fibrin. 

Since the discovery of the third corpuscle, or hsematdblast, hy 
Hayem and Bizzozero, the part taken by this element of the blood in 
the process of coagulation has been carefully studied by E berth and 
Schimmelbusch. The third corpuscle possesses a peculiar propert}' to 
adhere to any foreign body or irregularity of surface of the intima of 
the blood-vessels. The authors just quoted found that when a vessel is 
injured, as by tying a ligature around it and removing this in a quarter 
of an hour afterward, these minute blood-disks manifest a peculiar ten- 
dency to adhere to the injured part of the tunica intima and to each 

24 



370 



PRINCIPLES OF SURGERY. 



other, forming a white mural thrombus. The process by which mural 
implantation of the third corpuscle takes place these authors call conglu- 
tination, the mass thus formed being composed primarily and exclusively 
of this morphological element of the blood. If an aseptic thread is 
drawn across the lumen of a vessel in which the blood-current is moving, 
the third corpuscle is arrested in its course and becomes deposited upon 
the thread, which in time becomes the centre of a white thrombus. Con- 
glutination, under such circumstances, is a purely mechanical process. 

Eberth and Schiinmelbusch demonstrated by their experiments that 
conglutination is most liable to occur where irregularities of the tunica 
intima are present. If b}^ a trauma inflammatory or degenerative 

changes take place, the 
endothelial lining of 
a blood-vessel is ren- 
dered rou°h and un- 
even ; conglutination 
takes place first at the 
points which project 
farthest into the lumen 
of the vessel, because 
here the projecting 
body encroaches upon 
the axial current, 
which conveys the 
third corpuscle. In 
thrombosis through 
pathological causes, 
mural implantation of 
the third corpuscle 
takes place upon an 
intima roughened by 
inflammatoiy or degenerative changes. Thrombus formation, as we observe 
it in pysemia, always takes place upon a vessel-wall altered by action of pus- 
microbes. The form of thrombosis intimately associated with the etiology 
and pathological anatomy of pyaemia occurs in a vein within or in close 
proximity to the primary suppurative lesion. The close relationship of 
phlebitis to pyaemia was well understood by John Hunter, who believed 
that the former always preceded the latter. He taught that the phlebitis 
resulted in intra-venous production of pus and the formation of metas- 
tatic abscesses. Cruveilhier, on the other hand, regarded thrombosis as 
the first link in the chain of pathological conditions in pyaemia. The 
idea of a primary thrombosis as a cause of disease was carried b} T his 
pupils so far that nearly all inflammatory processes were by them attrib- 




Fig. 127. — White Thrombus. {Landerer.) 

a, slightly granular and hyaline masses produced by the third corpuscle; 
b, white corpuscles; d, young blood-vessel. 



ETIOLOGY. 



371 



uted to thrombotic changes in small veins ; not only inflammatory lesions, 
but even tumors were supposed to originate in this manner. A new 
aspect was given to the pathology of this disease by the careful experi- 
mental investigations of Yirchow on thrombosis and embolism. He 
showed that the metastatic deposits always occurred at points where 
vessels had been blocked by an embolus derived from a disintegrating 
thrombus. In the light of recent research phlebitis precedes thrombus 
formation at the primary seat of the infection. The pus-microbes which 




Fig. 128.— Red Thrombus. Mosaic of Red Corpuscles Traversed by Young 
Connective Tissue from the Intima Vessel- Wall, Infiltrated by a Few 
White Corpuscles. (Landerer.) 



are present in the infected tissues permeate the vein-wall and induce 
inflammatory changes characteristic of this form of infection. As soon 
as the infection has reached the intima this structure is roughened, and 
upon the projecting points conglutination takes place, and the foundation 
for thrombus is laid b} r a pavement composed of the third corpuscles of 
the blood. Upon this surface aggregation of the colorless corpuscles 
takes place, and, as these structures undergo coagulation necrosis, fibrin 
is formed and a red thrombus is established. 

The pus-microbes, which have reached the interior of the vein through 



372 



PRINCIPLES OF SURGERY. 



the inflamed vein-wall, multiply in the thrombus, and produce here, as 
elsewhere under similar favorable circumstances, their specific patho- 
genic effect. The thrombus thus formed is an infected thrombus which 
precludes the possibility of its removal bj* absorption. With an in- 
crease of the intra-venous infection coagulation is hastened, and a red 
thrombus soon fills the entire lumen of the vein, surrounded by a zone 
composed exclusively of blood-disks, colorless corpuscles, and fibrin, 
which compose its mural portion. As soon as the lumen of the vein has 
been completely obstructed the conditions for coagulation are improved, 
and the thrombus increases in size in both directions. The contact of 




Fig. 129.— Laminated Thrombus in a Vein. The Dark Granular Lay- 
ers are Composed of Colorless Blood-corpuscles and Fibrin; 
the Central. Lighter Portion, of Red Corpuscles. 1:97. {Birch- 
Hirschfeld. ) 



the blood with the dead, infected thrombus results in coagulation, and in 
this manner layer after layer is added to the thrombus. If thrombus 
formation take place in advance of the primary phlebitis, inflammation 
of the vein-wall follows as an inevitable consequence from the presence 
of the infected thrombus, the inflammatory process spreading like the 
infection from within outward. The growth of a thrombus is seldom 
arrested in a central direction until some large vein-trunk is reached, 
into which the apex of the thrombus projects. 

The blood-current in a vein into which the apex of a thrombus from 
an adjacent vein projects frequently arrests its proximal extension, but 



ETIOLOGY. 



373 



if the venous circulation is impeded, or the thrombus continues to grow 
by the addition of new layers, in spite of the obstacles presented, one 
portion after another of a vein becomes involved, and the thrombus 
rapidly increases in length in a proximal direction. A venous thrombus 
in a pysemic patient is only loosely attached to the vein-wall, as the 
pus-microbes transform the white corpuscles, which remain after coagu- 
lation has occurred, into pus-corpuscles, and in this manner softening 
and disintegration of the thrombus are accomplished. If a thrombus, at 
the point where it is in contact with the venous circulation on the proxi- 
mal side, become sufficiently softened, fragments become detached and 
are carried away by the venous current as emboli. 

Embolism. — An embolus is a detached thrombus, part of a thrombus, or 
any foreign substance transported by the arterial 
blood-current to its place of impaction. The process 
or act by which this is accomplished is called embolism. 
An aseptic embolus produces disturbances at the 
seat of impaction, which result exclusively from the 
sudden interruption of the blood-supply to the tissues 
fed by the obstructed vessel. The effect on the tis- 
sues is the same as though the vessel had been tied 
with an aseptic ligature. Yirchow found that aseptic 
caoutchouc emboli, introduced into the right side of 
the circulation through the jugular vein, produced 
no serious trouble after their impaction in the 
branches of the pulmonary artery. 

Panum ascertained, by his experiments, that 
small, simple emboli in the pulmonary artery become 
encysted. The emboli of foetal cartilage which 
Maas introduced into the jugular vein in dogs did 
no damage to the pulmonar}^ tissue, and not only 
retained their vitality but became the nucleus of 
a temporary tumor. An aseptic embolus, derived from plastic intra- 
vascular exudations or an aseptic thrombus, affects the tissues at 
the seat of impaction in the same manner as the aseptic substances 
which have been used to produce embolism artificially in animals. 
An embolus consisting of a fragment of an infected thrombus, as is the 
case in pyaemia, is a culture medium which contains the same microbes as 
caused the primary infection, and which at the seat of impaction estab- 
lishes an independent centre of infection, which etiologically and patho- 
logically is identical with the primary invasion. 

The embolic origin of metastatic abscesses was first pointed out by 
Virchow, who, at the same time, showed that the emboli are always 




Pig. 130.— Thrombo- 
phlebitis. {Billroth.) 

A, central end of venous 
thrombus projecting into a 
larger vein-trunk ; B, vein- 
branch not closed by a 
thrombus. 



374 PRINCIPLES OF SURGERY. 

derived from venous thrombi undergoing puriform softening. The 
closure of a vessel by thrombosis is always a slow, gradual process, 
while the obliteration of an artery by an embolus is the work of a 
moment. The gradual closure of a vessel by the slow growth of a 
thrombus is not attended by the same degree of disturbance of nutrition 
as when a vessel of similar size is suddenly blocked by the impaction of 
an embolus. Septic thrombo-phlebitis does not lead at once to embolism, 
as new layers are constantly being added to the proximal end of the 
thrombus, from where the fragments which constitute the emboli are 
alwa}'s derived. Embolism only occurs if the proximal end of the 
thrombus has become sufficiently softened that fragments separate spon- 
taneously and enter the venous circulation, or if the fragments are 
washed awa}^ by the venous current from a projecting thrombus. As 
the infected thrombus is always located in a vein within, or in close 
proximity to, the seat of primary infection, the detached fragments or 
emboli reach the right side of the heart with the venous blood, and, as 
they are usually too large to pass through the pulmonary capillaries, 
they become impacted in the branches of the pulmonary arteiy. The 
lung acts as a filter, and is therefore the most frequent seat of embolism 
and metastatic abscesses. The circulatory disturbances at the seat of 
impaction give rise to pathological conditions which are characteristic 
of embolism, and can be readily recognized in the examination of organs 
after death. The area of tissue affected by the sudden closure of a vessel 
by the impaction of an embolus is called an infarct, and the process which 
produced the pathological changes infarction. Infarcts are always 
wedge-shaped, the apex of the triangle corresponding to the location of 
the embolus, and the base to the ultimate branches of the obliterated vessel. 
Cohnheim has described what he calls a terminal artery, by which is 
meant one whose brandies inosculate only with those of the corre- 
sponding vein, one which is devoid of collateral anastomosis. Such are 
the renal and splenic arteries, and, in a less complete manner, those of 
the brain, heart, stomach, and lungs. If a terminal artery in the kidney 
or spleen is obstructed collateral circulation cannot be established, and 
necrosis of the tissues which depend on the closed artei\y for their blood- 
su PPly i s an inevitable consequence. The same result follows embolism 
of a terminal arter} r in the spleen. In the other organs which have been 
enumerated the terminal arrangement of the arteries is not as absolute, 
and embolism is not followed by necrosis with the same degree of 
certainty, as circulation can be restored, under favorable circumstances, 
by collateral branches. The first effect of the closure of an artery, 
by an embolus in any of these organs, is the appearance of a wedge- 
shaped area of ischsemia, which in size corresponds to the size of 






ETIOLOGY. 375 

the vessel obstructed. It may be so small that it can hardly be detected 
by the naked eye, or the base of the wedge may be 1^ inches in length. 
The border of this wedge-shaped space becomes the seat of active hyper- 
emia, the surrounding vessels undergoing rapid dilatation. The hyper- 
emia is usually so intense that rhexis takes place and the parts become 
infiltrated with blood ; hence the expression hsemorrhagic infarct. 

Hamilton is of the opinion that the hsemorrhagic infarcts in the lung 
are not caused by embolism, but by rupture of small vessels and haemor- 
rhage into the alveoli, the distribution of the fine branches of the bronchi 
determining the shape of the infarct. Although the ultimate branches 
of the pulmonary artery cannot be called terminal arteries, in the 
strictest sense implied by this term, if they become suddenly blocked by 
an embolus, collateral hyperemia is so intense that haemorrhage into the 




Fig. 131.— Embolus of Branch of Pulmonary Artery. Hemorrhagic Infarction 
of Alveoli. Chromic-Acid Specimen. 1:100. (Birch-Hirschfeld.) 

parenchyma of the organ frequently takes place, — a condition well 
represented in Fig. 131. 

In hsemorrhagic infarcts of the lung resulting from embolism the 
tissues involved are firmer than normal, and, on section, present pneu- 
monic appearances, which are due to infiltration with leucocytes and 
extravasation of blood, as well as transudation of blood-plasma through 
the walls of the l^peraemic blood-vessels surrounding the ischemic area. 
As the emboli usually lodge in the peripheral branches of the pulmonary 
artery, the infarcts are most frequently located near the surface of the 
lung. Immediately after embolism has occurred the district supplied by 
the obstructed vessel presents an anaemic appearance, which soon gives 
place to a reddish color, resulting from the hsemorrhagic infiltration. As 
in pyaemia the embolus conveys from the primary seat of infection the 



376 



PRINCIPLES OF SURGERY. 



specific microbes of suppuration, it becomes the centre of a suppurative 
inflammation. The pus-microbes multiply in their new location and at 
once induce a suppurative arteritis, and, after their passage through the 
inflamed vessel-wall, they attack the histological elements contained in 




Fig 132.— Pyemic Abscess of Lung. X 350. (Hamilton.) 

A, walls of alveoli: B, effused, small, round cells ; C, fibrin lying in alveolar spaces ; D, cell entangled in meshes 
of same; E, E, E, masses of micrococcus (staphylococcus) lying in exudation. 

the exudation, which breaks down, becomes purulent, and is converted 
into an abscess. In the lung the leucoc} T tes which are present in the 
infarct are converted into pus-corpuscles, and the interstitial connective 
tissue undergoes necrosis and can be found as detached shreds in the 
abscess. 



ETIOLOGY. 



377 



Embolism and metastatic abscesses, although more frequently found 
in the lungs in pyaemia, are not limited to this organ. To explain the 
occurrence of embolism in more remote organs, as the kidneys, spleen, 
liver, brain, etc., we must assume either that an embolus in the pulmonary 
artery becomes the nucleus of a thrombus, which, by its growth, reaches 
across the pulmonary capillaries and projects into the pulmonary vein, 
where fragments again become detached and enter the systemic circula- 
tion, or zooglcea of pus-microbes, passing the first filter (the lungs), are 
arrested in the capillaries of distant organs, or, finally, leucocytes im- 
pregnated with pus-microbes serve as minute emboli, and, after their 
localization in distant organs, become the cause of metastatic suppura- 




Fig. 133.— Coagulation Necrosis fkom a Kidney Infarct. X300. {Birch-Hirschfeld.) 

A, zone of reactive inflammation ; B, loss of nuclei in the necrosed epithelia. (The nuclei of connective- 
tissue cells are in part preserved.) 

tion. In the kidney the infarctions appear as sharply circumscribed 
areas of a pale, cream^ellow color. When cut into, the infarct has a 
wedge shape, the narrow end pointing to the hilus. The red zone is not 
so marked as in infarctions of the spleen, and the greatest vascularity is 
in the direction of the embolus. As in infarcts of the lung, the hy- 
persemic zone corresponds to the vessels nearest the ischaemic area. 
Extravasation of blood, although present, is never so marked as in the 
lung. The epithelial cells within the hypersemic zone are destroyed by 
coagulation necrosis, and if the embolus is aseptic this portion of the 
kidney is removed by molecular degeneration and absorption, leaving a 
cicatrix behind. 



378 PRINCIPLES OF SURGERY. 

Infarcts of the kidney occurring in pyaemia are converted into 
abscesses in the same manner as in the lungs, by the escape of pus- 
microbes from the embolus through the inflamed arterial wall into the 
tissues starved by defective blood-supply. 

SYMPTOMS AND DIAGNOSIS. 

As a wound complication pyaemia never occurs before suppuration 
has taken place, seldom before the seventh, usually about the ninth to 
eleventh, day after the accident or operation, if it is the result of a 
primary infection of the wound. In patients threatened with pj'aemia, 
an ill-defined train of premonitory symptoms precede the actual develop- 
ment of the disease These symptoms apply to the appearance of the 
wound and the general condition of the patient. The onset of the 
disease may be suspected at any time after suppuration has occurred, 
when evidences of serious capillary stasis manifest themselves at the 
seat of injury or operation. The thrombo-phlebitis gives rise to oedema; 
the margins of the wound appear puffed and elevated, the granulations 
pale and flabby ; suppuration, which may have been profuse, becomes 
scanty ; the pus changes its character, and, instead of a yellowish, cream- 
colored fluid, it becomes sanious, serous, or sero-sanguinolent. 

Careful inspection of the parts at this time may reveal the existence 
of thrombosis in one or more of the veins leading from the focus of 
primary infection. The general premonitory symptoms are indicated by 
a slight degree of intoxication, the result of the introduction into the 
circulation of pus-microbes and their toxins, from the primary focus of 
suppuration, causing a slight rise in the temperature and a general 
feeling of malaise, thirst, and loss of appetite. The actual development 
of the disease is initiated by a well-marked severe chill or rigor, which lasts 
from a few minutes to an hour or more. The chill resembles a malarial 
chill, and has often been mistaken and treated as such. Such a chill in 
a patient suffering from a suppurating wound or abscess is always an 
alarming symptom. It is an entirely subjective s}'mptom, as the ther- 
mometer placed in the axilla during the algid stage indicates a rise in 
the temperature, which often reaches 104° to 105° F. before the patient 
ceases shivering. 

Chills have been artificially produced in animals by the introduction 
of foreign substances into the circulation, and in pyaemia it is an indica- 
tion that fragments of an infected thrombus, and with them a large 
quantity of pus-microbes, have entered the circulation. The chill may 
recur at regular intervals daily or every other day, — a feature which may 
still further add to the difficulty in making a differential diagnosis 
between pyaemia and malaria. Usualty, however, the chill recurs at 



SYMPTOMS AND DIAGNOSIS. 379 

irregular intervals, one, two, or three times a day, as a rule, increasing 
in frequency, and often in intensity, as the disease progresses. If, for 
instance, during the first few days the patient has one chill daily, and, 
after a few days two or more during the same time, every additional 
chill indicates a more advanced stage of intoxication, and an increase in 
the number of metastatic foci. After the chill the fever continues for 
several hours, with a temperature of 103° to 104° F., until the appear- 
ance of profuse perspiration, when the temperature falls to normal, or 
even a little below that. The chill, fever, and sweating coming in the 
same order and of about the same duration as in malaria, the clinical 
picture resembles the latter almost to perfection, and on this account 
many cases of pyaemia have been mistaken in the beginning for malaria, 
and vice versa. 

The fever which attends pj'aemia always is of an intermittent or re- 
mittent type. In acute pyaemia the chills may return several times 
during twenty-four hours, the temperature between them showing re- 
missions, but seldom returning to normal. In subacute and chronic 
cases the remissions are well marked between the chills, the temperature 
often sinking below normal. Vomiting and diarrhoea are less constant 
S3'mptoms than in septicaemia. The pulse in its frequency corresponds 
to the temperature ; its force is always reduced by the depressing etfect 
of the toxins upon the heart. Delirium is occasionally present, but, as 
a rule, the mind is clear until the end. The yellowish color of the 
skin, almost constantly present in pyaemia, has been attributed to icterus, 
resulting from metastatic processes in the liver; but in the majority of 
cases it is not the result of retention and absorption of bile, but is caused 
by destruction of red blood-corpuscles and pigmentation of the tissues 
with the coloring material thus liberated. It is an icterus, which, on 
account of its origin, is called " hsematogenous icterus" The metastatic 
deposits in the kidneys are indicated by the appearance of albumen and 
sometimes pus in the urine. 

Metastatic Suppuration. — Infarcts in one or more of the internal 
organs are present in every case of pyaemia, and suppuration in some of 
the large cavities is of frequent occurrence. In reference to the number 
of secondary metastatic foci of suppuration, a great deal depends on the 
clinical form which the disease assumes. In the acute form, which 
proves fatal within one to three weeks, the infarcts are numerous and 
the abscesses quite small, while in some of the infarcts the existence 
of suppuration cannot be demonstrated macroscopically. In chronic 
pyaemia, in which life is prolonged for months, and sometimes even a 
year, the number of secondary foci are few, but they have resulted in 
the formation of large abscesses. The presence of infarcts of the lung 



380 PRINCIPLES OF SURGERY. 

are indicated by symptoms and signs which point to circumscribed foci 
of inflammation in this organ. If the infarct is immediately underneath 
the pleura, it gives rise to circumscribed pleuritis and sharp, lancinating 
pain at a point corresponding to the location of the infarct, always aggra- 
vated by the respiratory movements. In such cases friction-sounds can 
often be heard over the infarct. The consolidation of the tissues in- 
volved by the infarct by inflammatory infiltration from the vessels sur- 
rounding it is attended by crepitant rales, bronchial breathing, and 
dullness on percussion, over an area corresponding to the size of the 
infarct. A pulmonary abscess which takes the place of an infarct in- 
creases in size by encroaching upon the surrounding tissues, and in 
chronic cases may empty itself into a bronchial tube. A subpleural 
infarct, infected with pus-microbes, not infrequently leads to suppurative 
pleuritis and empyema by the extension of the infection from the lung- 
tissues to the adjacent pleura. In the same manner a suppurating 
infarct of the lung may become a direct cause of suppurative pericar- 
ditis, and p3 r ocardium if its location is adjacent to the pericardium. 
The onset of metastatic foci in the lungs is often insidious, and even 
large infarcts often occasion only slight subjective symptoms and ob- 
jective signs. Embarrassed breathing should admonish the attendant 
to search for evidences of multiple infarcts of the lung. Abscesses in 
the liver, caused by septic emboli, vary in size from that of a pea to an 
orange, but occasion no symptoms unless they are located immediately 
underneath the serous covering, when they cause localized pain. Embolic 
infarcts in the kidneys may be suspected if the urine contains albumen, 
or pus, or both. The spleen is always enlarged in pyaemia, but, as this 
is the case in all acute infective processes, the presence of an infarct or 
abscess is only to be suspected if the symptoms, especially pain and cir- 
cumscribed tenderness, point to the existence of perisplenitis. Enormous 
pyaemic abscesses often develop insidiously and without pain, or the 
ordinary symptoms of acute inflammation between muscles and in the 
subcutaneous connective tissue. Metastatic suppuration in p3'aemia 
takes place not only where infarction has occurred, but also in localities 
where the existence of embolism cannot be demonstrated anatomically, 
this being notably the case in joints and the large serous cavities. Sup- 
purative pericarditis, pleuritis, and peritonitis frequently complicate 
acute, rapidly-fatal p3 T aemia. Suppurative sj-novitis, multiple or limited 
to one joint, is a frequent complication, both in acute and chronic 
pyaemia. Metastatic suppuration in these localities develops without 
demonstrable infarcts, and occurs, in all probability, in consequence of 
mural implantation of pus-microbes or infected leucocytes upon the 
wall of capillary vessels, the intima of which has been damaged bj 7 toxins 



SYMPTOMS AND DIAGNOSIS. 381 

held in solution by the circulating blood. As in all cases of pyaemia 
pus-microbes and their toxins necessarily constantly enter the cir- 
culation from the primary focus of infection, the}' prepare the soil for 
the reception and pathogenic action of pus-microbes in the vessels and 
tissues of certain organs, more especially the synovial membrane of 
joints and the serous membranes lining the large cavities. Pjsemic 
abscesses, when well-developed, always contain yellow pus of the con- 
sistence of cream. Examined under the microscope, such pus contains 
corpuscles in which no sign of a nucleus can be found. 

The pus-microbes are always present in great numbers, both within 
the pus-corpuscles and in the pus-serum. While some doubt may remain 
after the first chill as to the nature of the disease, this doubt is dispelled 
with the recurrence of the chills. In acute cases the chill returns once 
or twice daity, but, unlike in cases of malaria, if the chill is of daily 
occurrence, it does not come at a fixed time, as is the case in malaria. 
If the disease does not culminate 

into a daily chill, the temperature ■ 'l^iv 

then shows an irregular remittent '\m 4-:^- : ^/^.'^o^^^W^ -^A ^^ 
type of fever. The patient loses m ^■ v * / ;'„.°°''^. '-v/ "> . '.,•'•': -"ir^ SI 
strength and flesh rapidly, and the n * : >lf 0^i '•*•'< •/•V>v ."!''{'• : ". 
face presents the color of a mixture 1M:^^^ ' ^■7.<^J^-'^° ■' K y°'' ]^} 
of the hectic flush with the icteric 



hue. While the pulse at first rises Iffi-^'-^Xy "- ^ J°. ^81 ^ 

only to 100 to 120 beats per minute '% '" 

during the febrile exacerbations, it Fio .^_ Py ^ mic Pus , showing com- 

soon remains at from 120 to 150 per *™ E nuclear destruction in 

1 Corpuscles and an Abundance of 

minute. Great thirst and complete pus-microbes within and between 

1 Pus-corpuscbes. (Landerer.) 

loss of appetite remain constant 

symptoms. The tongue and lips are dry, diarrhoea is more common 
as septic intoxication advances, and the stools are frequently stained 
with blood. As the fatal termination approaches, delirium and sopor 
come on, and under increasing symptoms of depression death takes 
place gradually from heart-failure, or suddenly from embolism of the 
pulmonary artery. In chronic cases the duration of the disease is 
sometimes prolonged for months, and Billroth relates a case where 
the patient lived for a year. In chronic cases the chills recur at long- 
intervals, and the fever assumes a remittent t} r pe between them. In 
still another class of chronic pyaemia the chills ultimately disappear, 
and the fever assumes a mild, continuous type, while the patient gradu- 
ally succumbs to decubitus, amyloid degeneration of internal organs, or 
a slow form of septic intoxication. 



382 PRINCIPLES OF SURGERY. 

PROGNOSIS. 

The prognosis of pyaemia is always grave. Acute pyaemia, in spite of 
all treatment, almost without exception terminates in death in from one 
to two weeks. The few recoveries which have been reported were cases 
of subacute or chronic pj-aemia. As pyaemia is not a primary, but sec- 
ondary, condition, it is a fatal disease from the very beginning, as during 
its commencement transportation of infected tissue has taken place to 
localities usually inaccessible to radical treatment. In acute cases death 
seldom takes place before the end of the first week, more frequently from 
the second to the end of the third week. In chronic cases not compli- 
cated by pulmonary infarcts, the metastatic suppuration in parts accessi- 
ble to surgical treatment are occasionally amenable to successful treat- 
ment, and a cure can be obtained after a long and lingering illness. 
Prospects of a successful issue in chronic cases can be only entertained 
when the disease attacks young individuals otherwise in good health. 
The prognosis of pyaemia is also modified by the location of the primary 
focus of infection, as when this is not accessible to direct treatment the 
disease will progress uninfluenced by general treatment. If, on the 
other hand, further supply of septic material from the primary infection- 
atrium can be prevented by a prompt removal of the infected tissues, 
one of the most important indications of treatment has been met, and 
the hope of a favorable termination has been thereby increased. 

PATHOLOGICAL ANATOMY. 

The pathological changes found in patients who have died of pyaemia 
are characteristic. The primary focus of infection may no longer be 
present, as it may have healed, but, as a rule, this has not occurred, and 
examination shows a suppurating wound, an abscess, an osteomyelitic 
focus, a suppurating phlebitis or sinus phlebitis. The vein in which the 
fatal thrombus formed may not be a large one ; indeed, it may be so 
small as to elude detection by macroscopical examination. If the imme- 
diate cause of the p3^aemia,the thrombosed vein, can be located, it will be 
found filled with a softened, loose blood-clot, which is very variable in 
length, and the proximal end of which projects usually into the lumen 
of some larger vein-trunk on the proximal side. The vein-wall itself is 
in a state of suppurative inflammation that prevents the formation of 
firm adhesions between the thrombus and the intima, as we find it in 
cases of plastic thrombo-phlebitis. The new histological elements that 
are produced by the inflammatory process are at once converted into 
pus-corpuscles, and some of these are distributed through the substance 
of the blood-clot, and furnish an additional cause for the softening and 
disintegration of the coagulum. The infarcts are most numerous in the 



PATHOLOGICAL ANATOMY. 383 

lungs, but are also found in the spleen, kidneys, and liver. An embolus 
catches in an artery at a point where the lumen suddenly becomes 
smaller, which is the case where the vessel bifurcates. The embolus, 
after it has become impacted, becomes the nucleus of a thrombus, as the 
blood which comes in contact with it undergoes coagulation, and in this 
manner layer after layer are added on each side. As the embolus under 
these circumstances is alwa}^s composed of dead infected material, it 
causes at the seat of impaction a specific inflammation, which in every 
respect represents the type of inflammation at the primary seat of infec- 
tion. As the tissues which are in immediate contact with the embolus are 
the coats of an artery, a suppurative arteritis follows the impaction, and 
as soon as the pus-microbes have passed through the softened, inflamed 
arterial wall the infection extends to the tissues weakened by the sudden 
abstraction of blood ; that is, the tissues which are within the borders of 
the wedge-shaped infarct. The hyperaemic zone around the infarct con- 
stitutes a wall of protection against unlimited extension of the infection 
and inflammation. In the lungs the infarct becomes rapidly infiltrated 
with the products of inflammation from the hj^peraemic zone, which gives 
rise to consolidation of that portion of the lung. Suppuration is 
attended by liquefaction of the exudation, and the infarct is transformed 
into an abscess. 

In p3^8emia the emboli that reach the systemic circulation are smaller 
than those which reach the pulmonary artery ; consequently the infarcts, 
as a rule, in the kidney, spleen, liver, and other distant organs are smaller 
than those in the lungs. In metastatic suppuration without embolism, 
in the strict sense in which this word has been heretofore used, the pus- 
microbes which become implanted upon capillary walls, changed by the 
action of pre-existing toxins diffused in the blood, reach and infect 
the paravascular tissues and the interior of large cavities, thus causing 
a rapidly spreading, diffuse, suppurative inflammation. In metastatic 
suppurative inflammation of the synovial membrane of joints, the peri- 
toneum, pleura, and pericardium, the process represents all the essential 
features of a specific surface inflammation, characterized by rapid exten- 
sion of the inflammation over the whole surface and the accumulation 
of a large purulent collection in a short time. Microscopical examina- 
tion of nearly all organs in fatal cases of pyaemia reveals the existence of 
coagulation necrosis resulting from the action of pus-microbes and their 
toxins upon tissues with which they have been brought in direct con- 
tact. The spleen is always enlarged and softened, even if no infarcts 
are present. The heart is flaMry and the muscular tissue softened. The 
intestinal mucous membrane is swollen, vascular, softened, and at points 
shows submucous extravasation from rupture of capillary vessels, — 



384 PRINCIPLES OF SURGERY. 

evidences that this structure has also become the seat of metastatic inflam- 
mation. Embolism of cerebral vessels is an unusual occurrence in 
pyaemia, while they are frequently obstructed by emboli which become 
detached from valvular vegetations in the left side of the heart. 

TREATMENT. 

Before the use of antiseptics in surgery, pyaemia figured largely 
as the cause of death after injuries and operations. Only twenty -five 
years ago a large percentage of the surgical patients in the old, in- 
fected, European hospitals died from this disease. Insignificant injuries 
and minor operations were frequently followed by this fatal complica- 
tion. At present it is a source of pride to the teachers of surgery, if 
during a course of lectures they do not succeed in finding a case for clin- 
ical study and instruction. In hospitals where antiseptic surgery is 
thoroughly and conscientiously practiced the disease is almost unknown. 
Helpless as we still are in curing the disease, as surely can we prevent 
it, in the management of recent injuries or intentional wounds, if we re- 
sort to careful and efficient antiseptic precautions. The prevention of 
suppuration in a wound furnishes absolute protection against pyaemia. 
Again, the early radical treatment of suppurative lesions has been the 
means of diminishing the frequency of pyaemia from causes other than 
wounds. The prophylactic treatment of pyaemia consists in preventing 
suppuration in wounds by antiseptic means, and in sterilizing suppurating 
foci before septic thrombo-phlebitis has occurred by early incision, anti- 
septic irrigation, drainage, and in maintaining asepticity under antiseptic 
dressings. 

In the treatment of suppurating wounds a great deal can be done 
toward the prevention of pyaemia b} r resorting to thorough secondary 
disinfection, and in guarding against tension and accumulation of the 
products of septic inflammation hy efficient drainage, or, still better, by 
combining drainage with permanent irrigation. Suppurative osteomye- 
litis should be treated by early operative measures, not only for the pur- 
pose of preventing unnecessary destruction of bone and of relieving 
pain, but more particularly with a view of warding off this fatal compli- 
cation. Klebs has recently made the suggestion to surgeons that the 
prophylactic treatment of pyaemia should be carried still farther, by 
excising such veins as are known to contain infected thrombi before 
embolism has taken place. The justifiability and advisability of such 
treatment cannot be doubted, and surgeons will be glad to adopt this 
suggestion in cases where it is possible to ascertain the location of the 
thrombosed vein or veins, and where such an operation is feasible on 
anatomical grounds. A number of successful curative operations have 



TREATMENT. 385 

been performed during the last five years in cases of incipient pyaemia 
following thrombo-phlebitis of the sigmoid sinus in cases of suppurative 
inflammation of tiie middle-ear. The operation consists in ligating the 
internal jugular vein on the corresponding side below the thrombus if 
this has extended to the vein, and in exposing and removing the sup- 
purating thrombus from the sinus. This operation should be performed 
in every case of suppuration of the middle-ear as soon as this complica- 
tion can be recognized. Salzer operated on two such cases by opening 
the lateral sinus and removing the septic thrombus, and one of his cases 
recovered. Keen in addition ligatecl and divided the internal jugular 
vein on the corresponding side below the thrombus which had formed 
in it, but his patient died. The most characteristic symptoms of septic 
thrombosis of the lateral sinus are: tenderness along the course of the 
internal jugular vein, evidences of disturbed circulation in the region of 
the ear, and, if the thrombosis has extended to the internal jugular vein, 
emptiness of the vein below the thrombus. Puncture with the needle of 
an hypodermatic S} T ringe will show at once whether the lumen of the 
sinus is occluded. In grave cases of osteomyelitis an operation for this 
special indication would often make it necessary to amputate, as even 
the most thorough scraping out of the infected medullaiy cavity might 
fail in removing all of the infected thrombi. It has also been suggested 
to interrupt the venous circulation in one of the principal venous trunks 
of a limb by ligation, for the purpose of preventing mechanically the 
entrance of detached fragments of a thrombus into the circulation ; but 
this procedure has not answered the expectations, as the emboli will 
reach the general circulation through collateral branches. Removal of 
the infected thrombi b}' amputation or resection of the affected portion 
of a vein are more reliable prophylactic measures than ligation in the 
continuity of a principal vein-trunk on the proximal side of the primary 
seat of infection. Detachment of fragments of a disintegrating throm- 
bus must be prevented as far as possible by securing absolute rest for the 
infected part, as all sudden movements, active and passive, and sudden 
disturbances of the circulation may become the means of separation of 
fragments, and their transportation as emboli into the circulation. The 
curative treatment of pyaemia, medical and surgical, is unsatisfactory. 
Quinine, natrum benzoicum, and the different preparations of salicylic 
acid have been used quite extensively in the treatment of the fever which 
attends the disease. Antifebrin, antipyrin, and other drugs of the same 
class of remedies are worse than useless, as the favorable effects from their 
antipyretic action are more than overbalanced by the harm they do in 
depressing the action of the heart. External heat and the internal ad- 
ministration of diffusible stimulants should be used to shorten the dura- 

25 



386 PRINCIPLES OF SURGERY. / 

tion of the rigors. Alcoholic stimulants are indicated in the acute and 
chronic forms of the disease. 

In chronic pyaemia a daily tepid bath is of the greatest value. In 
the same class of cases it is of the utmost importance to support the 
patient's strength by systematic feeding and the use of the malt bever- 
ages, such as beer, ale, and porter, with a view of prolonging life until 
the primary cause is eliminated from the primary and secondary depots 
of infection, spontaneously or by surgical treatment. In acute cases of 
pyaemia, originating from a wound of one of the extremities, or from acute 
suppurative osteomyelitis of the long bones, the question of removal of 
the primary focus of infection by amputation will present itself. 

If, from a study of the symptoms, it become apparent that multiple 
infarcts exist in the lung, or lungs, and other organs, amputation is not 
permissible, as it would 011I3 7 result in shortening the life of the patient. 
The propriety of an amputation should only be considered in the begin- 
ning of the disease, and before extensive dissemination of the purulent 
infection by embolism has taken place. In a suppurating, compound 
fracture, amputation may be indicated for other reasons than those of a 
threatened or developed attack of pyaemia. Secondary disinfection of a 
suppurating wound with excision of thrombo-phlebitic veins, where this is 
possible, should be practiced in all cases of pyaemia for the purpose of 
preventing or limiting general dissemination by embolism. In chronic 
cases the secondary metastatic processes should receive early and 
careful attention. 

As in these cases the metastatic suppuration, as a rule, is not caused 
by embolic infarcts, life is threatened by the secondary lesions, from 
which ptomaine intoxication is maintained, and from which new places 
may become infected by localization of pus-microbes in capillary vessels 
weakened 4 by the action of toxins. If the metastasis is limited to one 
or more joints and the disease pursue a chronic course, very satis- 
factor} T results can be obtained by tapping and washing out the joints 
with a 3-per-cent. solution of carbolic acid. The tapping and irrigation 
should be repeated as often as the effusion returns. In a case of genuine 
pyaemia following a gunshot wound of the leg, complicated by secondary 
haemorrhage and gangrene, that recently came under my observation, I 
performed amputation and later tapped both shoulder-joints and the left 
sterno-articular joint repeatedly and followed the tapping in each 
instance by antiseptic irrigation. The patient finally recovered and the 
joints thus treated were movable. For thirty-five days he consumed, on 
an average, a quart of whisky daily, and I attribute the favorable result 
largely to this energetic stimulation. Suppurating joints are incised, 
drained, and irrigated under strict antiseptic precautions, and, if the 



SEPTICOPYEMIA. 387 

metastatic suppuration is limited to a single joint, this can be done with 
a fair prospect of a favorable result. Purulent collections in the serous 
cavities or connective tissue are dealt with in a similar manner. Careful 
attention to diet and the sanitary surroundings of the patient, combined 
with energetic surgical treatment of the suppurating foci, will, at least 
occasionally, be rewarded by an ultimate recovery. 

SEPTICOPYEMIA. 

In the absence of more accurate knowledge concerning the microbic 
cause of septicaemia, we must, at least for the present, assign to septi- 
caemia and pyaemia the same bacteriological cause. That pus-microbes 
can produce septicaemia when introduced into the circulation in sufficient 
quantity has already been shown, and that pus-microbes have been 
frequently cultivated from septic products is a matter of demonstration ; 
hence the disease, if not identical with p3 T aemia, from a bacteriological 
stand-point, is at any rate closely allied to it. It has also been shown that, 
in case the life of a septic patient is prolonged for a sufficient length of 
time, the metastatic foci of inflammation are the seat of incipient suppu- 
ration ; hence such cases resemble p3 7 aemia upon a pathological basis. 
In pj'aemia, after cessation of the rigors, which are the most character- 
istic clinical symptom of this disease, the fever resembles septicaemia, 
and, as the clinical picture thus developed rests upon pathological con- 
ditions t}'pical of pyaemia, it would be proper to apply to such cases the 
term septico-pyasmia. For the same etiological and pathological reasons 
we apply the same term to septicaemia in which post-mortem examination 
reveals the presence of minute, multiple, suppurating foci. 

Septico-p3 r aemia may be defined as a condition in which the s} r mp- 
toms indicate the presence of both septicaemia and pyaemia, and in which 
the post-mortem appearances point to septic and purulent infection. 
Leube described such a combination of the two diseases, which as yet are 
considered as distinct, occurring in patients in whom he was unable to 
trace the source of infection from without ; hence he called the affection 
spontaneous septico-pyaemia. Litten, on the other hand, in similar cases, 
was alwa} r s able to locate the infection-atrium, but the primary infection 
at the time acute symptoms set in had either disappeared or its location 
could only be ascertained by most careful examination. Jiirgensen 
applied to these cases the lengthy compound word " kryptogenetic- 
septico-pyaemia" as he was unable to find a tangible infection-atrium. 
In a recent article on the subject he gives an account of 100 cases that 
came under his own personal observation. The patients were usually 
attacked first with acute pharyngitis, and, as this stage was generally 
attended by a chill and a general feeling of malaise, the patients generally 



388 PRINCIPLES OF SURGERY. 

attributed the onset of the disease to exposure to cold. In most cases 
the general infection was announced by a severe chill. Rapid loss of 
strength was one of the most prominent symptoms ; the patients in a 
few hours after the chill became utterly prostrated. The symptoms 
which pointed to local processes during life were referred most frequently 
to the lungs, liver, spleen, pleura, heart, and the long bones. Whether 
the primary affection occurred through the pharynx, where the first 
symptoms were manifested, could not be definitely ascertained. In the 
acute cases the symptoms were grave from the beginning and increased 
in intensity as the infection progressed, while, in the chronic cases, 
infection is kept up from some suppurating focus, and the disease may 
continue for several years. Subcutaneous and retinal hemorrhagic 
extravasations were frequently observed. Post-mortem examinations 
revealed suppuration in some of the internal organs, and vascular 
changes which are characteristic of sepsis. 

These cases may be compared with acute suppurative osteomyelitis, 
where, after the most careful inquiry and the most scrutinizing examina- 
tion, we often fail in furnishing reliable evidence for locating the primary 
source of infection. It is possible that the pus-microbes enter through 
an intact or inflamed mucous membrane, or through the appendages of 
the skin, and that they remain in a latent, inactive condition until a 
weak point is created somewhere in the body, where they localize in a 
soil prepared for their reproduction and pathogenic action ; or, what is 
more likely the case, they enter through an abrasion or sl ; ght lesion, 
which may be so insignificant that the patient himself fails to notice 
it, and produce no symptoms until, by accident or disease, a proper 
soil is prepared for the initiation of an acute attack in one or more of 
the internal organs. The remote dangers which may follow infection 
through an insignificant wound, or from a small, suppurating focus, 
should remind the surgeon of the importance of treating these little 
ailments with the necessary care and attention, and b} r so doing he will 
often be the means of preventing fatal complications. In two cases of 
kryptogenetic septico-pysemia that have come under my own observa- 
tion the disease was complicated by ulcerative endocarditis. In one of 
these cases the immediate cause of death was gangrene from embolism 
of the popliteal artery. 



CHAPTER XV. 

Erysipelas. 

Erysipelas is a self-limited, acute, non suppurative inflammation of 
the lymphatic vessels of the skin or mucous membrane, attended by red- 
ness and a continued type of fever. As a wound complication it occurs 
independently of suppuration, and in its uncomplicated pure form 
remains as a superficial affection, the inflammation never passing beyond 
the structures of the skin or mucous membrane. 

HISTORY OF ITS MICROBIC ORIGIN. 

The contagiousness of erj^sipelas has been recognized for centuries, 
and on this account early attempts were made to include it among 
microbic diseases. In 1868 Hueter maintained that erysipelas and hos- 
pital gangrene were identical diseases and caused by the same micro- 
organism. Its microbic nature was again made the subject of investi- 
gation in 1872, when Nepveau discovered micrococci in the blood of 
erysipelatous patients. Wilde detected the same microbes in the blood, 
but asserted that similar microorganisms could be found in the pus in 
wounds from which the erysipelas developed. 

In 1874 Recklinghausen found masses of micrococci in the lym- 
phatic channels in the inflamed skin at the border of an erysipelatous 
inflammation. Nearly the same time similar observations were made 
by Billroth, Ehrlich, Tillmanns, and Koch. Tillmanns produced the 
disease artificial^ in animals by injecting subcutaneously the serum con- 
tained in the bullae of erysipelatous skin. 

Koch attempted to produce the disease artificially in rabbits with 
injections of different putrid fluids, but failed until he made inoculations 
with mouse-dung softened in distilled water. He injected the material 
under the skin of the ear, and produced an inflammation which in its 
course resembled erysipelas. The swelling and redness spread slowly 
downward from the point of inoculation. On the fifth da}' it had 
extended as far as the root of the ear. The ear became exceedingly 
vascular, so that the separate vessels could no longer be identified, while 
the tissues were softened and cedematous. The animal died on the seventh 
day. Blood taken from the heart of this animal produced no effeot in 
other rabbits. No microbes could be found in the blood or in any other 

(389) 



390 



PRINCIPLES OF SURGERY. 



organ except the affected ear. In transverse sections of the ear the 
blood-vessels were seen to be markedly dilated, full of red corpuscles, 
and surrounded b}' the nuclei of white corpuscles. Between these and 
the cartilage-cells bacilli were found. 

The bacilli were present close to the cartilage only. Here they were 




\\Ni.# 



V 






l 



// 

Fig. 135.— Section of Ear of Rabbit Parallel to Surface of Cartilage. 
The Morbid Process Resembled Erysipelas. X 700. (Koch.)* 

A, ball-like accumulation of bacilli ; B, accumulatiou of nuclei above the layer of bacilli ; C, 
nuclei of flat cells connected with the cartilage below the layer of bacilli ; D, bacilli arranged parallel 
to each other. 



found in large clusters, from which the bacilli radiate in all directions. 
This net-work of bacilli extended over the whole cartilage of the ear on 
both surfaces. Inflammation was most marked in the vicinity of the 
bacilli, and, consequently, in the absence of other causes, there could be 
no doubt that the erysipelatous inflammation was caused by these 

* Copied from " Traumatic Infective Diseases," by permission of the New Sydenham 
Society, London. 



DESCRIPTION" OF STREPTOCOCCUS ERYSIPELATOSIS. 391 

microbes. Orth found micrococci in the contents of the bullae of erysip- 
elas. Recklinghausen and Lukowsky found them in the lymphatic ves- 
sels and the connective-tissue spaces in the structures affected by 
erysipelas. Billroth and Ehrlich found bacteria not only in the lym- 
phatic vessels, but also in the blood-vessels of the inflamed skin. Till- 
manns found microbes in erysipelatous skin, and Letzerich, in cases of 
erysipelas attacking vaccination wounds, found them in the wound itself, 
in the blood-vessels, muscles, liver, spleen, and kidneys. The essential 
specific cause of erysipelas was finally discovered by Fehleisen in 1883. 
He cultivated the microbe from erysipelatous products, and demon- 
strated its essential etiological relationship to erysipelas by producing 
the disease artificially, in animals and man, by inoculations with pure 
cultures. From the morphological appearance of the microbe and its 
direct etiological bearing to erysipelas he called it the streptococcus of 
erysipelas. With pure cultures of this microbe he produced by inocula- 
tions not only erysipelas in animals, to prove its specific pathogenic 
qualities, but successful inoculations were also made in man for thera- 
peutic purposes. 

DESCRIPTION" OF STREPTOCOCCUS ERYSIPELATOSIS. 

The streptococcus erysipelatosis, discovered by Fehleisen, when 
examined under the microscope appears in the 
form of chains, the links of which are minute 
cocci, 3 to 4 micromillimetres in diameter. 

The streptococcus of erysipelas invades the 
superficial lymphatic channels of the skin or 
mucous membrane exclusively, but it can also 
be found in the serum contained in bullae. Each If 

coccus, when it is about to divide, becomes larger F ^ K y%pbi!aS^s. C Pukb 
and oval, and soon appears made up of two hemi- atst^^tained^vith 
spherical masses, the two new cocci resulting from F <^5? ) N X 95 ° ( - Baum ~ 
fission of the old one. Morphologically, the strep- 
tococcus of erysipelas and the streptococcus pyogenes are nearly iden- 
tical, only that the cocci of erysipelas are somewhat larger, while both 
are somewhat smaller than the staphylococci. 

CULTIVATION. 

This microbe can be readily cultivated in bouillon at ordinary room- 
temperature ; also upon gelatin, agar-agar, and solidified blood-serum. 
Upon solid nutrient media the appearances of the cultures resemble very 
strongly those of streptococcus p}^ogenes. There is less tendency, 
however, to the formation of terraces the margin is thicker and more 





~o 


; 


v., .-•>* 

\ J 4 
v 


C5sJ 
\ 



392 



PRINCIPLES OF SURGERY. 



irregular in outline, and the appearance of the growth is more opaque and 
whiter. Rosenbach mentions, as another distinguishing feature between 
the two, that the culture of the streptococcus of erysipelas represents 
the shape of a fern, while the outlines of the cultures of the pus-strepto- 
coccus describe the shape of an acacia-leaf. The culture appears as a 
very delicate grayish-white film. The growth is very slow, and the 
individual colonies remain small. The streptococcus of erysipelas does 
not liquefy gelatin. The microbe of erysipelas grows equally well 

when oxygen is excluded. If gelatin is inoculated 
by puncturing with a needle charged with a pure 
culture, microscopical colonies can be seen the whole 
length of the track of the needle at the end of 
twenty-four hours. In four days the culture has 
reached the height of development, and colonies the 
size of a grain of sand to that of a pin's head occupy 
the whole length of the needle-track. 

In cultures the microbe retains its pathogenic 
qualities for about four months. 

INOCULATION EXPERIMENTS. 

Fehleisen produced, artificially, typical erysipe- 
las in rabbits by injecting pure cultures under the 
skin of the ear. Koch and Gaffky used cultures 
grown upon solidified blood-serum and inoculated 
9 rabbits. In 8 of these typical erysipelas de- 
veloped, the attack lasting from six to twelve days. 
Krause obtained positive results by inoculat- 
ing gray mice. In all cases where the inoculation 
proved successful the erysipelatous inflammation 
started at the point of inoculation, and extended 
rapidly, always following the lymphatic channels. 
In Krause's experiments the animals died after three 
or four days, even when only a minute quantity of 
the culture was injected under the skin of the back. Examination of the 
infected tissues after death showed that inflammation followed the 
invasion of the microbes, and consequently the principal pathological 
changes were found within and in the immediate vicinity of the tymphatic 
channels. 

INOCULATION FOR THERAPEUTIC PURPOSES. 

As soon as it was demonstrated experimentally that simple, uncom- 
plicated erysipelas is a disease attended by but little danger to life, the 
suggestion was near that, if the disease could be artificial!}' produced in 



\ 



Fig. 137.— Stale Cul- 
ture of Streptococ- 
cus of Erysipelas in 
Gelatin at Ordi- 
nary Temperature 
of Room, Four Days 
Old, Natural Size. 
(Baumgarten.) 



INOCULATION FOR THERAPEUTIC PURPOSES. 393 

man by inoculation with pure cultures, the local and general conditions 
thus produced might prove useful in the cure or amelioration of some 
diseases not amenable to operative treatment and internal medication. 
Of t persons the subjects of incurable tumors, inoculated by Fehleisen 
with pure cultures, 6 developed typical erysipelas ; in the seventh case the 
patient had passed through an attack of erysipelas only a few weeks 
previously, and was, in all probability, still protected against a new 
attack. This patient was inoculated a second time with a negative 
result. In other instances a second inoculation failed after a successful 
inoculation. The period of incubation was fixed at from fifteen to sixty- 
one hours. The microbe was found only in the lymphatic vessels and con- 
nective-tissue spaces, and when the culture was pure suppuration was never 
produced. Fehleisen has seen, by this treatment, a cancer of the breast 
become smaller, a lupus disappear almost completely, while a case of 
fibro-sarcoma and another of sarcoma were not materially affected by 
this method of treatment. Janicke and Neisser have recorded a death 
from erysipelas thus intentionally produced in a case of cancer of the 
breast beyond the reach of an operation. At the necropsy it was proved 
that the tumor had almost completely disappeared, and the microscopical 
examination of portions that had remained appeared to show that the 
tumor-cells had been destined through the direct action of the microbes. 
Biedert saw, in a child suffering from a sarcoma involving the posterior 
part of the cavity of the mouth and pharynx, the left half of the tongue, 
the naso-pharyngeal space, and the right orbit, the tumor disappear 
almost completely during an attack of erysipelas. Cases, on the other 
hand, have been reported in which, after an accidental or intentional 
attack of erysipelas, the tumor commenced to grow more rapidly. 
Neelsen reports a case of carcinoma of the breast, in which, after two 
severe attacks of ei^sipelas, the tumor not only commenced to grow 
faster, but at the same time the regional infection progressed also more 
rapidly. 

Babtchinsky made the accidental discovery that the microbe of 
erysipelas is a direct antagonist to the virus of diphtheria. His son, 
while suffering from a most severe attack of diphtheria, was suddenly 
attacked by erysipelas. This complication, grave of itself, seemed to 
hasten the fatal termination of the case, and during the first few hours 
of the eruption the patient was much worse. But the next day the 
symptoms had much improved, and the patient made a rapid recovery. 
Following this indication Babtchinsky inoculated a second case of 
diphtheria with a culture of the microbe of erysipelas grown on agar- 
agar, and with an equally happy result. Since this time, of 14 cases of 
diphtheria treated with these inoculations, 12 resulted in recovery, and, 



394 PRINCIPLES OF SURGERY. 

as in the 2 cases resulting fatally the inoculation produced no effect, 
these negative results only tend to confirm the efficacy of the curative 
inoculations. It is remarkable that in all of the cases where erysipelas 
was produced artificially this disease pursued a mild course, and the 
patients recovered rapidly from both diseases. 

Schwimmer gives an account of 11 cases of lupus in all of which 
no improvement was observed after an intercurrent attack of erysipelas. 
In a case of keloid an attack of erjsipelas was followed by marked 
improvement, and a lipoma underwent a similar favorable change from 
the same cause. Sj 7 philitic lesions he saw temporarily benefited, while 
the erysipelas had no effect in permanently influencing the course of the 
disease. 

Bruns gives an account of the effect of erysipelas on tumors in 22 
patients. Among these 3 cases of sarcoma were permanently cured. 
Two cases of multiple keloid after burns were also cured. In 4 cases 
of lymphoma of the neck some of the glands became smaller and some 
disappeared. In 5 cases the er3 T sipelas was artificially produced b}^ 
inoculation with a pure culture. In 3 cases of carcinoma of the mamma 
1 was not influenced by the disease, 1 became one-half smaller, and 1 was 
reduced to a small induration in the scar, the size of a pea. A multiple 
fibro-sarcoma was greatly benefited, while an orbital sarcoma was not 
improved. 

Coley has made extensive use of a combined sterile culture of the 
streptococcus of erysipelas and the bacillus prodigiosus in the treatment 
of inoperable malignant tumors. From his published reports it appears 
that a number of cases of sarcoma were permanently cured. The writer 
has given this treatment a faithful trial in 9 cases of inoperable malig- 
nant tumors — 2 cases of carcinoma and 7 cases of sarcoma — during the 
last few years, with uniform negative results. In some of these cases 
the reaction was so intense that the general health was much impaired 
by the treatment. 

In view of the uncertainty of the result, and the not inconsiderable 
danger which attends the intentional form of erysipelas in patients 
debilitated by antecedent disease, it is safe to predict that no further 
inoculations will be made in man until, perhaps, future research will 
demonstrate a certain specific antagonistic action of the streptococcus 
of erysipelas against some other pathogenic microbes the cause of grave 
diseases not amenable to successful treatment by less heroic measures. 

MANNER OF INFECTION. 

An intact skin or mucous membrane furnishes absolute protection 
against infection with the streptococcus of erysipelas. This microbe 



MANNER OF INFECTION. 395 

cannot reach the lymphatic vessels without an infection-atrium, which 
may be a small abrasion, a wound, blister, ulcer, — in fact, any breach of 
continuity in the skin or mucous membrane. Before antiseptic surgery 
was practiced infection frequently occurred through accidental or inten- 
tional wounds. Antiseptic surgery has greatly diminished the frequency 
of traumatic erysipelas, but has not completely eradicated it, as an 
occasional case will occur in the hands of the most careful antiseptic 
surgeons. Even before the microbic cause of erysipelas was known, 
Trousseau, one of the closest of clinical observers, claimed that infection 
with the virus of erysipelas is only possible through some wound or 
abrasion of the skin ; the latter may be so insignificant as to be unnotice- 
able and entirely overlooked by both patient and physician. Idiopathic, 
or spontaneous, erysipelas, so called, does not exist ; every case of ery- 
sipelas is traumatic, in so far that by injury or disease the necessary 
infection-atrium must be created through which the streptococcus can 
reach the lymphatic vessels. In erysipelas without a tangible infection- 
atrium, infection occurs through a minute puncture or abrasion, which 
may, perhaps, never have attracted the patient's attention, and which 
has become invisible at the time the disease is first noticed. Infection, 
however, may also take place through a mucous membrane, through 
which the microbes enter the tissues in the same manner and under the 
same conditions as when infection takes place through the skin. One of 
the severest cases of erysipelas that ever came under my observation 
commenced in the pharynx, or tonsils, and, as the sj-mptoms subsided 
here, a t}^pical and severe facial e^sipelas developed. As the patient 
was suffering at the same time from secondary syphilis, it is probable 
that the streptococcus of erysipelas entered the tissues through the 
secondaiy s^^philitic lesions in the pharynx. In the tissues the strepto- 
coccus of erysipelas invades the l} r mphatic channels exclusive! j r , and 
manifests here its specific pathogenic qualities. 

The erysipelatous inflammation is, in reality, a specific, progressive 
lymphangitis, the paralymphatic tissues becoming affected by contiguit} T . 
Within the lymphatic channels the microbe multiplies, and diffusion of 
the infection takes place in the course of the lymphatic vessels, but does 
not always follow in the course of the lymph-stream. The lymphatic 
vessels are often found crowded with the microbe, which is destroyed in 
a short time, as with the subsidence of the inflammation the microbe 
disappears. According to Koch and Fehleisen, the microbe is always 
found most numerous in the portion of the skin correspond ing to the 
border of the inflamed area. At this point the lymphatics frequently 
appear completely blocked by dense colonies of this microbe, so that no 
lymph-corpuscles can be seen among them. As the inflammation extends 



396 



PRINCIPLES OF SURGERY. 



to the surrounding connective tissue, some of the microbes leave the 
lymphatics and enter the connective-tissue spaces, where they come in 
contact with the inflammatory exudation. Within the lymphatic vessels 
the streptococci are found between the lymph and colorless blood-cor- 




Fig. 138.— Section through Skin near the Margin of the Erysipelatous 

Zone. X 700. {Koch.) 

1, 1, each a tymphatic vessel filled with streptococci in chains. 

puscles ; in the connective tissue they are found also within the proto- 
plasm of leucocytes. 

Metschnikoff maintains, in opposition to most of the modern au- 
thors, that the arrest of the extension of the eiysipelatous inflammation 
is accomplished by phagocytosis. The accumulation of leucocytes 
in the inflamed tissues has, undoubtedly, a salutary effect in mechani- 




Fig. 139.— Section of Skin in Erysipelas, after Cornil and Babes. X 600. 

v, v, section of two lymphatic vessels containing white corpuscles and chains of cocci ; m,m, chain cocci; 
t, connective tissue ; a, connective tissue and migrating cells. 



cally blocking the avenues through which infection takes place; but as 
most of the microbes are outside of, and not within, the leucocytes 
and lymph-corpuscles, it is difficult to conceive how limitation of the 
extension of the infection could be accomplished solely by phagocytosis. 
The microbes have a very short existence in the tissues ; the inflammation 



RELATION OF ERYSIPELAS TO PUERPERAL FEVER. 397 

which they initiate continues for some time after all microbes have dis- 
appeared. The toxins which microbes secrete produce protoplasmic 
alteration of the connective-tissue cells and the capillary blood-vessels, 
which prolong the inflammation beyond the period when the tissues are 
in a sterile condition. Others have claimed that self-limitation of ery- 
sipelas is due to destruction of the microbes by the high temperature 
which attends the disease. De Simone has recently shown that pure 
cultures of the streptococcus of erysipelas lose their power of reproduc- 
tion if they are exposed for two days consecutively to a temperature ol 
39.5° to 41° C. Clinical experience, however, has demonstrated conclu- 
sively that erysipelas is not arrested in its course by a temperature ot 
40° C. or more. It appears that the streptococcus exhausts the soil of 
the nutrient material which it requires for its growth and reproduction 
in a short time. In the blood-vessels of the inflamed skin no strepto- 
cocci can be found, but that they occasionally enter the blood-vessels is 
sufficiently evident from the occurrence of metastatic erysipelas and the 
direct transmission of erysipelas from mother to foetus by infection 
through the placental circulation. As the streptococcus of eiysipelas 
produces its pathogenic effects in the lymphatic vessels and diffuses 
itself through these channels in the tissues, it becomes obvious that in 
all cases infection takes place as soon as localization is effected in the 
superficial lymphatic structures, or in the spaces contributary tG them 
and in direct connection with an infection-atrium. 

RELATION OF ERYSIPELAS TO PUERPERAL FEVER. 

Obstetricians recognized the danger of exposing puerperal women 
to the infection which might emanate from erysipelatous patients long 
before the microbe of erysipelas was known. Since the discovery of the 
microbe by Fehleisen, this subject has attracted renewed attention, and 
positive knowledge has accumulated both from accurate clinical observa- 
tion and from the fertile and more positive field of experimentation 
Gusserow asserted, upon the basis of an extensive experience, that no 
direct etiological relations exist between the contagium of erysipelas and 
puerperal fever. He had under his care puerperal women suffering- from 
erysipelas of the skin without any serious disturbances following in the 
genital tract. In 10 other cases, 1 of them occurring during an epi- 
demic of puerperal fever, the erysipelas was observed as a complication 
of septic affections of the genital organs. Gusserow claims that in this 
case it cannot be claimed that erysipelas could have caused the puerperal 
affection, as the latter preceded the former. But another point could be 
raised, as it might be claimed that the septic processes should be made 
answerable for the occurrence of erysipelas. This author has studied 



398 PRINCIPLES OF SURGERY. 

this subject also by way of experiment. A pure culture of the strepto- 
coccus erysipelatosis, which had been tested and found reliable in pro- 
ducing erysipelas by the usual methods of inoculation, was injected into 
the peritoneal cavity of 2 rabbits ; in 2 others it was applied to an 
open wound of the abdomen, and in the last 2 animals it was injected 
into the subserous connective tissue of the peritoneum. In all of these 
animals no effect was produced, and no pathological changes were detected 
at the point of injection when the animals were killed, some time after the 
inoculation. Grusserow looks upon the results of these experiments, if 
not as positive proof, nevertheless as strong evidence against the claim 
that erysipelas can cause puerperal sepsis. Winckel, an equally reliable 
and able observer, has come to entirely opposite conclusions. He culti- 
vated from a parametritic abscess, which had developed after childbed, 
Fehleisen's streptococcus. Injections- of this culture into rabbits pro- 
duced typical erysipelas. The same author also observed erysipelas fol- 
lowing in a puerperal woman suffering from suppurative perimetritis, 
pleuritis, and metro-lymphangitis. The patient died on the thirteenth 
day. The starting-point of the erysipelas could be traced to an ulcer of 
the vulva. Blood taken from the right side of the heart soon after death 
was inoculated upon a solid nutrient medium, and produced a culture of 
the streptococcus of eiysipelas. The same culture was obtained by in- 
oculations with fluids taken from the peritoneal and pleural cavities, the 
uterus, kidneys, and the liver. In 3 cases a culture thus obtained was 
injected into the peritoneal cavity of rabbits, and no peritonitis followed. 
In one experiment the injection produced suppurative peritonitis. 
Guinea-pigs proved less susceptible to infection than rabbits. In white 
mice the inoculations were invariably productive of a fatal disease. 
From the results of these experiments the author claims that the virus 
of erysipelas is one of the most, virulent puerperal poisons, and believes 
that they prove the causal relations of erysipelas to puerperal sepsis. 

Doyen also found, both in mild and severe cases of puerperal fever, 
a streptococcus similar to the one described by Rosenbach and Fehleisen. 
He made some inoculations to determine the relationship between puer- 
peral sepsis and erysipelas. The streptococcus found in the infected 
tissues of puerperal-fever patients caused erysipelas, and the streptococ- 
cus found in erysipelas developed puerperal fever. From his own obser- 
vations and experiments the author arrived at the conclusion that the 
microbe of puerperal sepsis is the same as that of erysipelas. From a 
clinical and bacteriological stand-point it is evident that puerperal sepsis 
from intection with the streptococcus of erysipelas can onl} T occur when 
the streptococcus is brought in contact with an absorbing surface in 
the genital tract ; but when this takes place, and the microbes reach the 



PHLEGMONOUS INFLAMMATION AND SUPPURATION. 399 

enlarged lymphatic vessels of the puerperal uterus, the most violent and 
fatal form of puerperal sepsis is almost certain to follow. 

RELATION OF ERYSIPELAS TO PHLEGMONOUS INFLAMMATION AND 

SUPPURATION. 

Some difference of opinion still exists, among bacteriologists, with 
regard to the question whether the streptococcus of erysipelas possesses 
pyogenic properties. The majority of those who have studied this 
subject experimentally do not consider the streptococcus of erysipelas as 
a pus-microbe, and assert that when suppuration takes place in erysipelas 
it is the result of a secondary infection with pus-microbes, and, on this 
account, look upon phlegmonous inflammation as a complication, and not 
as a condition belonging to the erysipelatous process. Hajeck made 
careful investigations to show that the streptococcus of erysipelas is 
neither in form nor culture materially different from the streptococcus 
pyogenes, but he showed, also, that in 51 cutaneous or subcutaneous in- 
oculations with a pure culture of the streptococcus of erysipelas in rabbits 
the result was always a superficial migrating dermatitis which resembled 
to perfection erysipelas in man, while similar injections with the strepto- 
coccus of pus produced a more intense and deeply-seated inflammation, 
which in almost every instance terminated in suppuration. The differ- 
ence in the action of the two microbes on the tissues plainly demon- 
strated their non-identity. Microscopical examination of the inflamed 
tissue showed a still more important difference as far as the localization 
and local diffusion of the microbes were concerned. The microbe of 
erysipelas was always found with the products of inflammation within 
the lymphatic vessels, and only exceptionally in the connective-tissue 
spaces, which anatomically are only a part of the lymphatic system. 
The pus streptococcus penetrates the tissues more deeply ; it is not only 
found in the lymphatic vessels and connective-tissue spaces, but it mi- 
grates beyond the lymphatic channels and infects different kinds of tissue, 
thus giving rise to a more deeply seated and more intense inflammation. 
The streptococcus of erysipelas is found only exceptionally in the im- 
mediate vicinity of blood-vessels, while the microbe of pus can always be 
seen arranged in radiate lines around vessels entering the adventitia, the 
muscular coat, and often even in the lumen of the vessel. In man the same 
histological differences can be seen in the tissues the seat of erysipelatous 
and phlegmonous inflammation as in the artificial conditions in animals 
subjected to experiment, and the same pathological differences are also 
constant^ found. The author asserts that Fehleisen was in error when 
he claimed that the formation of abscesses occurred independent^ of the 
erysipelatous infection. He affirms that, in rabbits inoculated with the 



400 PRINCIPLES OF SURGERY. 

virus of erysipelas, after the acute inflammation has subsided circum- 
scribed small nodules which remain may suppurate, but suppuration 
never becomes diffuse; while after injection with cultures of the strepto- 
coccus pyogenes the inflammation assumes a phlegmonous t3*pe and the 
suppuration is always more diffuse. Hajeck maintains that under certain 
circumstances a circumscribed superficial suppuration can also take 
place in erysipelatous inflammation in man. When suppuration in a 
joint takes place, however, it is not caused by the erysipelatous infec- 
tion, but is due to the presence of pus-microbes. Eiselsberg, Bonome, 
Bordini, Passet, and Simone are of the opinion that the streptococcus 
of erysipelas and the streptococcus of suppuration do not differ in their 
pathogenic effects. 

Smirnoff found in one case of erysipelas the specific microbe in the 
metacarpophalangeal joint of the left hand, which was the seat of the 
disease. In the case of a man who had died of erysipelas, enormous col- 
onies of the streptococcus were found in the right shoulder- and knee- 
joints. The synovial fluid injected into rabbits occasioned er'ysipelas 
migrans. According to the recent researches of von Lingelsheim, the 
streptococcus pyogenes differs from the streptococcus erysipelatosis in 
being pathogenic both for mice and rabbits, while the latter is patho- 
genic for rabbits only. 

Kheiner found Fehleisen's streptococcus in all cases of traumatic 
erysipelas which he examined, but was unable to find it in 2 cases of 
gangrenous ei'3 7 sipelas following t} T phus. In these cases he found bacilli 
which he believed were identical with Klebs-Eberth's bacillus of typhus. 
At the present time the opinion of the identity of the microbes of pus 
and ei*3'sipelas is again gaining ground. Schonfeld found the same coccus 
in the lungs and especialty in the dilated lymphatics of this organ in a 
patient who died from the effects of an attack of erysipelas complicated 
by fibrinous pneumonia. Mosny obtained a pure culture of the strepto- 
coccus of erysipelas from the inflamed lung of a servant who attended 
his master during an attack of facial erysipelas and who died the second 
da}r after an attack of pneumonia. Jordan, who is a firm believer in the 
non-specific nature of the microbe of erysipelas, made a careful clin- 
ical and bacteriological study of 2 cases of erysipelas in the clinic at 
Heidelberg. In the first case the disease started as a typical facial ery- 
sipelas and which was attended by phlegmonous inflammation of the 
forehead and adipose tissue of the orbital regions, and was soon fol- 
lowed in rapid succession bj r metastatic periostitis of right fibula, ery- 
sipelas of skin of leg, migrating pneumonia of both lungs, dilatation of 
heart, recurring erysipelas of face. The patient finally recovered. From 
all of the lesions, local and distant, he cultivated the staphylococcus 



SYMPTOMS AND DIAGNOSIS. 401 

pyogenes aureus. The nurse who attended this patient was taken with 
facial erysipelas on the third day, and from the serum obtained from a 
puncture near the erysipelatous zone he cultivated the same microbe. 

Kahlden, after a careful study of the recent literature on erysipelas 
and the difference in opinion on the pathogenic properties of the strep- 
tococcus erysipelatosis, remarks that the subtility in the differences 
between the morphology and the cultures of the microbe of erysipelas 
and the streptococcus of suppuration is undoubtedly the reason why no 
uniformity of opinion exists in regard to their specific pathogenic effects, 
especially as to the possibility of Fehleisen's streptococcus producing 
suppuration. To this I might add that not every superficial diffuse 
inflammation of the skin is erysipelas, and not every abscess occurring 
during, or soon after, an attack of erysipelas should be considered as a 
product of the erysipelatous infection. The surgeon will do well to 
adhere to the teachings of Fehleisen, who is positive in his assertion 
that the streptococcus of erysipelas never produces suppuration, until 
more convincing proof shall have been furnished of the pathogenic 
identity of the streptococcus of erysipelas and the streptococcus of 
suppuration. 

SYMPTOMS AND DIAGNOSIS. 

Erysipelas, like most of the acute infectious diseases, has no well- 
marked premonitory stage, the attack being sudden and followed by all 
the symptoms which usher in an acute febrile affection. The period of 
incubation in man has been fixed at from fifteen to sixty-one hours by 
the inoculations which have been made to produce the disease artificially 
for therapeutic purposes. Inoculations prove successful if the skin is 
punctured with a needle the point of which had been dipped into a pure 
culture of the streptococcus. Such punctures have no visible lesion 
after a few hours, — a fact which readily explains the disappearance of a 
visible infection-atrium at the time the disease appears, in cases of 
eiysipelas developing without a demonstrable breach of continuity in 
the skin. 

In the adult the disease commences, almost without exception, with 
a chill which sometimes amounts to a severe rigor. Nausea and vomiting 
are often present during the first few hours. The chill is followed by a 
rise in the temperature, which in a few hours increases to 104° F. or 
more. The fever assumes a continuous type, and in uncomplicated cases 
the difference between the morning and evening temperature is slight. 
Headache, thirst, and complete loss of appetite are constant and promi- 
nent symptoms. The pulse is at first full and bounding and seldom 
exceeds 100 beats per minute. In severe cases delirium is present 
almost from the beginning, and continues until the fever subsides. 

26 



402 PRINCIPLES OF SURGERY. 

Almost simultaneously with the appearance of the general symptoms, the 
skin in the immediate vicinity of the infection-atrium shows evidences of 
the existence of a superficial inflammation. The patient complains of 
a sense of tightness in the part, which is accompanied by a burning and 
itching sensation. 

In traumatic erysipelas the wound presents no changes in its appear- 
ance ; if suppuration is present the purulent discharge becomes some- 
what diminished in quantity and the pus is rendered more serous. The 
skin around the seat of infection is firmer to the touch, and, if the 
erysipelas has started from a wound, infection has occurred from a 
certain portion of the wound, while the remainder shows no evidences 
which point to erysipelatous inflammation. The skin which is involved 
by the erysipelatous inflammation presents, almost from the beginning, 
a characteristic rose or crimson color. With the appearance of the 
typical discoloration the inflammatory exudation has reached its height. 
The color disappears under pressure, but upon the removal of the press- 
ure no depression is left, showing that little or no oedema is present. 
The induration of the skin is most marked at the border of the erysipe- 
latous zone, and disappears with the absorption of the inflammatory 
product and the return of the natural color of the skin. The margin of 
the zone is abrupt and distinct on the side of the healthy skin. The 
border of the erysipelatous zone is not straight, but irregular, and often 
fan-like projections can be seen and felt which project into the healthy 
skin, and, when present they are characteristic, almost pathognomonic, of 
this form of dermatitis. The degree of swelling varies according to the 
intensity of the infection and the anatomical structure of the part 
involved. 

If the infection is intense and parts are implicated which are 
abundantly supplied with loose connective tissue, the swelling is greater 
than in cases where the infection is mild or the skin is stretched over 
firm, resisting parts. In facial erysipelas, for instance, the swelling is 
much greater around the orbits than in the scalp, because in the former 
locality the loose, cellular, connective tissue underneath the skin becomes 
swollen and oedematous from the escape into it of the inflammatory 
transudation. 

The specific mriammation, starting from the point of infection, 
spreads continuously and uninterruptedly along the course of the super- 
ficial lymphatics, but is not limited to the direction of the lymph-current. 
The intra-lymphatic diffusion of the streptococcus is not a passive, but 
an active, process. As this microbe is non-motile, its transportation in a 
direction opposite to the lymph-stream can only occur by its reproduc- 
tion. The lymph-current in most, if not all, of the inflamed lymphatic 



SYMPTOMS AND DIAGNOSIS. 403 

vessels is temporarily arrested by the blocking of the interior of the lym- 
phatic vessels with colonies of the streptococcus and the accumulation of 
lymph-corpuscles; consequently the colonies become fixed points from 
which new tissues are infected by their increase in size in all directions, 
owing to rapid reproduction of the microbe. The fever continues until 
the infection comes to a stand-still. The intensity of the subjective 
symptoms does not always correspond with the temperature, as patients 
may feel quite well when the temperature registers 104° to 105° F., 
while others show evidences of a serious disturbance with a much lower 
temperature. Large bullae usually result from confluence of a number 
of vesicles. The contents of these blisters are first serous, but suppu- 
ration may follow later from the entrance of pus-microbes. Bullae with 
hemorrhagic contents denote a grave attack. 

The duration of erysipelas is extremely variable. Genuine erysipelas 
may run a typical course and terminate in recovery in two days, or the 
disease may extend over a period of two weeks or more. The extent of 
surface successively invaded determines its duration. If it start from 
a wound of the hand it may extend along the forearm and arm to the 
shoulder, from here along the back to one or both of the lower extremi- 
ties, and before such a large territory of skin has passed through all the 
stages of the disease more than four weeks may elapse. As soon as the 
disease ceases to migrate the general symptoms subside, and within a 
few days the skin returns to its normal condition and the patient 
recovers his usual health in a remarkably short time, — a fact which tends 
to prove that erysipelas, in its uncomplicated form, does not impair the 
function of any of the internal organs to any considerable extent. 
Exfoliation of the skin is a usual occurrence. In the differential 
diagnosis we have to consider lymphangitis, erythema, phlegmonous 
inflammation, and thrombo-phlebitis. In lymphangitis from other causes 
than the streptococcus of erysipelas the inflammation follows larger 
lymphatic channels, which appear as red lines, and seldom, if ever, is the 
skin proper inoculated in the inflammatory process, while erysipelas 
is a combination of lymphangitis with dermatitis. Erythema appears 
as circumscribed points of inflammation in the skin with healthy tissue 
between, while, on the other hand, erysipelas shows no such interruptions, 
the inflammation being a continuous, uninterrupted process followed by 
speedy repair. Phlegmonous inflammation is accompanied by inflamma- 
tion of the skin, which in its external appearances closely resembles 
erysipelas; but the differential diagnosis rests on the location of the 
primary inflammation, which is always the superficial lymphatics of the 
skin in erysipelas and the subcutaneous tissue in phlegmonous inflam- 
mation. In phlegmonous inflammation the deep-seated inflammatory 



404 PRINCIPLES OF SURGERY. 

exudation is the primary pathological condition, and the lymphangitis 
follows as a secondary result, while in erysipelas the primary specific 
lymphangitis and dermatitis are primary conditions, and if the subcu- 
taneous tissue become involved later on it must be regarded as a com- 
plication, and not as an integral part of the disease. Patients suffering 
from erysipelas complain of a smarting, burning, or itching sensation in 
the affected skin ; phlegmonous inflammation is attended by severe 
pain, which is of a throbbing character. Thrombo-phlebitis, starting 
from a chronic ulcer of the leg, has often been mistaken for erysipelas, 
not only by laymen, but also by physicians. Thrombo-phlebitis is often 
attended by inflammation of the tissues around the inflamed vein and of 
the superimposed skin, but the inflammation follows in the course of the 
vein, and not in the course of Lymphatics ; at the same time the vein can 
be felt as a solid, tender cord. 

CLINICAL FORMS OF ERYSIPELAS. 

The clinical forms of erysipelas are identical in so far that they are 
all caused by the same microbe, and that the disease primarily consists 
of a specific lymphangitis and dermatitis ; but the} r vary greatly, accord- 
ing to the location and structure of the part affected, the intensity of 
the infection, and the existence of complications. 

Erysipelas Erythematosum. — This is the mildest form of erysipelas. 
It is described as erythematic because the affected skin shows but little 
swelling, and the affection appears more as an efflorescence than an 
inflammation. No bullae form, and only slight exfoliation takes place 
during convalescence. 

Erysipelas Bullosum. — In this form the inflammation of the skin is 
more intense and the swelling more marked, in consequence of which 
blisters or bullae form underneath the cuticle. The pathological con- 
dition resembles a burn in the second degree. Removal of the cuticle 
leaves the papillary kyer of the skin exposed. The bullae often become 
the seat of secondary infection with pus-microbes, which transform the 
serous contents into pus. From such superficial foci of suppurative 
inflammation may develop what has been termed 

Phlegmonous Inflammation. — As we are not in possession of con- 
clusive proof that the streptococcus of eiysipelas possesses p3^ogenic 
properties, we can only explain the occurrence of phlegmonous inflam- 
mation of the tissues underneath the skin affected by er} T sipelatous 
inflammation by taking it for granted that the deep-seated phlegmonous 
inflammation is caused not only by the streptococcus of erysipelas, but 
by the accidental entrance into the tissues of microbes of suppuration. 
As soon as secondary infection with pus-microbes takes place the clinical 



CLINICAL FORMS OF ERYSIPELAS. 405 

picture of erysipelas is overshadowed or obscured by the suppurative 
inflammation. The typical general and local symptoms which char- 
acterize the erysipelatous inflammation give way to symptoms which 
indicate the existence of a diffuse suppurative inflammation. The tem- 
perature shows greater remissions, and the pulse becomes more rapid 
and feeble. The tongue is often red and dry, while all of the remaining 
symptoms point to intoxication from absorption of toxins produced 
in the tissues b}^ the pus-microbes. The swelling of the part affected is 
no longer limited to exudation into the substance of the skin, but affects 
mainly the deep-seated tissues. 

We have reason to believe that in most, if not in all, cases of 
phlegmonous erysipelas the secondary infection with pus-microbes takes 
place from a superficial suppurating focus as from a suppurating bulla, 
and that the microbes from here invade the subcutaneous connective 
tissue. The phlegmonous inflammation spreads with great rapidity, so 
that in a few days the skin of an entire extremity may become under- 
mined with pus, the patient, in the meantime, having complained but 
little of pain. Such an extremity on palpation imparts the sensation 
of a partially filled diffuse abscess-cavity. The external appearances 
furnish, often, no reliable indications of the extent of the deep-seated 
destruction. If incisions are made at this time a large quantity of pus 
escapes, mixed with shreds of necrosed connective tissue, and examina- 
tion reveals extensive destruction of the subcutaneous connective tissue 
and intermuscular septa. Phlegmonous inflammation, as a rule, does 
not attack tissues the seat of an erysipelatous inflammation, but the 
tissues weakened by this disease and infected with pus-microbes. A 
sudden increase in the temperature of patients suffering from erysipelas 
is often the first symptom which commences this complication, and such 
an occurrence should admonish the attendant to detect it early in order 
to subject it to timely and efficient treatment. 

Erysipelas Gangrenosum. — This is an exceedingly grave form of 
erysipelas. Most of the authors are of the opinion that if the strepto- 
coccus of erysipelas multiplies with sufficient rapidity, in the interior of 
the lymphatic vessels and the connective-tissue spaces, so as to com- 
pletely block these channels by its growth, a sufficient amount of 
toxins is produced to cause necrosis of the tissues, and under such 
circumstances the erysipelatous inflammation terminates in gangrene of 
the skin. This gangrene may take in circumscribed multiple patches, so 
that after separation and elimination of the dead tissue the skin presents 
a cribriform appearance or it may involve a large district of the skin, 
and then give rise to extensive loss of this structure in case the patient 
survives the disease. As the gangrene often commences in the portion 



406 PRINCIPLES OF SURGERY. 

of skin covered by bullae, it still remains an open question whether it 
results from the action of the streptococcus of erysipelas or whether 
it is the result of a secondary infection with pus-microbes. Isolated 
patches of gangrene of the skin are met with in many cases that termi- 
nate in recoveiy, but extensive gangrene of the skin is always a serious 
complication, as it may result in death from septicaemia, or, if life is not 
destroyed, it at least greatly protracts the recovery, and often calls for a 
tedious treatment to restore the lost tissue by skin-grafting. 

Erysipelas Metastaticum. — By metastatic eiysipelas is meant the 
occurrence of an erysipelatous inflammation in an organ or a part where 
the process developed separately from the primary field of infection. If, 
for instance, erysipelas should appear in an extremit}' opposite to the 
one primarily affected, without extension of the disease across the skin 
of the trunk, it would furnish a good example of what is meant by 
metastatic erysipelas. Again, if, during an attack of erysipelas of one 
of the extremities, the patient should be attacked with symptoms of men- 
ingitis, and at the necropsy the streptococcus of erj^sipelas could be 
demonstrated in the inflamed envelopes of the brain, this would furnish 
another illustration of metastatic erysipelas. Two possibilities present 
themselves in explaining the occurrence of metastatic eiysipelas. In the 
first place, colonies of the streptococcus in an active condition might 
reach a part distant from the erysipelatous inflammation with the lymph- 
current, and, meeting with favorable conditions, might establish an addi- 
tional focus of eiysipelatous inflammation, which, of course, would have 
to be necessarity in a part between the primary field of infection and 
the termination of the lymphatic vessels leading from the infected dis- 
trict. If no such connection can be established, then the metastatic 
process results from the entrance of streptococci in an active condition 
into the circulation and their localization in distant parts or organs by 
mural implantation upon the walls of capillary vessels prepared for their 
localization and reproduction. In most instances metastatic erysipelas 
is of such an embolic origin. 

The occurrence of metastatic erysipelas of the skin or exposed 
mucous membrane could also be satisfactorily accounted for by the 
microbes entering the tissues from without through a new and distant 
part of entrance, and in such a case it would not be in the form of a 
metastasis, but the result of a new inoculation in a different part of the 
body. 

Erysipelas Migrans. — Migration of the inflammatory process is one 
of the characteristic clinical features of erj^sipelas. In ordinary cases 
migration is limited to the anatomical region affected. In cases of facial 
erysipelas the disease seldom spreads beyond the scalp, and in eiysipelas 



CLINICAL FORMS OF ERYSIPELAS. 407 

of the extremities the disease usually subsides after it has extended over 
an extremity. Migrating erysipelas is that form of the disease where 
the erysipelatous inflammation extends from place to place, and from 
limb to limb. I have seen this form most frequently in infants, starting 
from the umbilicus or the external genital organs. I have seen it start 
from these points, ascend in an upward direction along the anterior 
aspect of the body, and, after reaching both shoulders, spread to the 
upper extremities, later to descend down the back, and finally terminate 
in the toes, after traveling nearly over the whole surface of the body. 
Erysipelas of the extremities or trunk never extends to the face or scalp, 
while, in exceptional cases, erysipelas of the face assumes the migrating 
form. Migrating erysipelas is usually attended by only moderate swelling 
and slight constitutional disturbances. One peculiarity of this form 
of erysipelas is that the same regions may become involved a second 
time. 

Erysipelas Facialis. — This is the so-called spontaneous or idiopathic 
form of erysipelas, as in most cases even close inspection does not reveal 
the existence of an infection-atrium. The disease usually commences in 
one of the alae, or at the root of the nose, — localities where minute skin 
lesions are frequently produced, and localities which, more than any 
other part of the face, are exposed to infection by contact. As far as 
its extension is concerned, facial erysipelas pursues the most typical 
course. The inflammation spreads toward the cheek and orbit on the 
side first affected, and then creeps across the bridge of the nose to the 
opposite side, to follow a similar course here. About the second or third 
day it reaches the forehead, and from here and the outer margins of the 
orbits it invades the scalp, to terminate, usually about the end of a week, 
at the nape of the neck. The chin and anterior aspect of the neck 
never become affected in facial erysipelas. Facial erysipelas is attended 
by considerable swelling, the eyes being often completely closed by the 
oedematous lids. Bullae form frequently about the centre of the cheeks 
and the forehead." One of the dangers of facial erysipelas consists in 
the direct extension of the erysipelatous inflammation from the skin 
along- the blood-vessels to the meninges of the brain. The meningitis 
under these circumstances is not a metastatic process, but the result of 
a direct extension of the inflammation from the skin to the meninges, 
along- structures which connect them through the intervening- skull. 
Patients who have suffered from facial erysipelas are not protected 
against subsequent attacks ; in fact, experience has shown that they are 
more prone to infection in the future than persons who have never 
suffered from this disease. If the bullae suppurate, there is always 
danger arising from suppurative thrombo-phlebitis, suppurative lepto- 



408 PRINCIPLES OF SURGERY. 

meningitis, and suppurative encephalitis, — fatal complications plainly 
attributable to secondary infection with pus-microbes. 

Traumatic Erysipelas. — We have seen that, in the strict sense of the 
word, all cases of erysipelas are traumatic in their origin, in so far that 
infection never takes place through the intact skin or a mucous membrane ; 
consequently, the disease never occurs without an infection-atrium, which 
may be a wound or a lesion of the surface through which the strepto- 
coccus gains entrance into the lymphatic channels. The expression 
" traumatic erysipelas " is still retained for the purpose of designating 
erysipelas as one of the numerous forms of wound complications. If a 
recent wound is infected with the microbes of erysipelas the disease de- 
velops within fifteen to sixty-one hours after the accident or operation. 
The disease may occur in consequence of later infection at any time 
before cicatrization is completed, as granulations furnish no absolute 
protection against infection. I have seen the disease originate more 
frequently in granulating than in recent wounds, — a strong argument in 
support of the advice that full antiseptic precautions should not be relin- 
quished until the healing process is completed, if the patient is to be pro- 
tected against an attack of erysipelas. Another important fact should 
alwa3 r s be remembered : that small wounds are more frequently attacked 
by erysipelas than large wounds, because the latter receive more careful 
attention, and are, as a rule, subjected to more rigid antiseptic treatment. 

PROGNOSIS. 

Simple uncomplicated eiysipelas is not a fatal disease unless it 
attacks infants or persons debilitated b}^ age or antecedent diseases. 
Death is caused more frequently by complications. The most common 
fatal complications are suppurative inflammation at the seat of erysipe- 
latous inflammation, or metastatic suppuration in distant parts or organs, 
resulting from secondaiy infection with pus-microbes, or, finalbr, ex- 
tension of the erysipelatous inflammation to important organs, as the 
brain or its envelopes, in cases of facial eiysipelas, or the occurrence of 
metastatic erysipelas in vital organs from embolic processes. The prog- 
nosis is, therefore, based largely upon the absence or presence of com- 
plications, which must be carefully sought for in all cases where general 
or local symptoms point to their existence. The temperature, pulse, 
and condition of nervous and digestive organs furnish important and 
valuable prognostic indications. 

TREATMENT. 

The number of specifics which at different times have been recom- 
mended in the local and general treatment of erysipelas must throw 



TREATMENT. 409 

doubt upon the efficacy of any local applications or internal remedies 
in arresting the further progress of erysipelas. At the same time it 
must not be forgotten that uncomplicated erysipelas is a disease which 
tends to spontaneous recovery, and seldom proves fatal, even if it is al- 
lowed to pursue its own course, unaided by any local application or in- 
ternal medication. The erysipelatous inflammation is of short duration, 
and passes through its different stages uninfluenced by local or general 
treatment. Since its microbic origin has been suspected different meth- 
ods of treatment have been recommended to arrest the further progress 
of the disease by destroying or rendering inert the primary cause. 
Hueter aimed at the destruction of the specific microbe by injecting, 
at different points at the border of the erysipelatous zone, 5 to 6 cubic 
centimetres of 3-per-cent. solution of carbolic acid. This method of treat- 
ment in the hands of others has been followed almost without exception 
by negative results. It is possible that subcutaneous injections of a 
l-to-1000 solution of corrosive sublimate in non-toxic doses would } 7 ield 
better results. The continued application of cold, even of an ice-bag, 
has been found useless in arresting: the disease. As it has been found 
that a temperature of over 40° C. continued for two days has at least 
an inhibitory effect on the growth of the streptococcus of erysipelas in 
artificial nutrient media, it would appear rational to resort to hot anti- 
septic compresses in the local treatment of erysipelas. If the area 
involved is limited, a compress, saturated with a weak hot solution of 
corrosive sublimate, would answer a most admirable purpose. If a large 
surface is affected, some of the weaker germicidal solutions could be used 
in the same manner. Moisture and heat relieve also the burning, smart- 
ing sensation more promptly and efficiently than the different filth}' oils 
and salves which have been employed. Application of tincture of iodine, 
muriated tincture of iron, and solutions of nitrate of silver are worse 
than useless, because they destroy the skin, which should be carefully 
preserved in order to protect the patient against secondary infection 
with pus-microbes. One of the best local applications is alcohol, either 
pure or slightly diluted. 

Recently Kraske recommended multiple minute incisions or, rather, 
scarifications in the skin, at the peripheral zone of the erysipelatous 
inflammation, for the purpose of preventing further extension of the 
disease. If the skin is first rendered aseptic, and subsequent secondary 
infection is guarded against by the application of a reliable anti- 
septic, this treatment may prove valuable in modifying the progress 
of the disease. After scarification a hot, moist, sublimated compress 
should be applied, to be immediately replaced by another when removed. 
The external use of ichtlryol, so highly recommended by Nussbaum, has 



410 PRINCIPLES OF SURGERY. 

proved useless in my hands, both in relieving suffering and in prevent- 
ing the extension of the disease. 

St. Klein appears to have obtained better results. He has treated 
31 cases of eiysipelas with ichthyol applied externally, with excellent 
results. In his experience the disease seldom resisted this treatment for 
more than three or four days. He uses a preparation composed of equal 
parts of ichthyol and vaselin, which is applied two or three times over 
the parts affected. Before the first application is made the skin is 
thoroughly cleansed with warm water and soap. After the ointment is 
rubbed in gently the surface is covered with a compress saturated with 
a solution of salicylic acid and over this a thick la3 r er of cotton. 

Wolfler has recently called attention to the value of the mechanical 
treatment of erysipelas. He has published 18 additional cases of ery- 
sipelas treated by pressure of strongly adhesive plasters. After the 
plaster is applied the disease extends into the compressed parts of the 
skin, which swell considerably and remain swollen for several days, and 
then both the swelling and the fever diminish. He recommends that by 
wa}r of precaution a second line should be commenced several centi- 
metres distant from the first. The part must be carefully inspected once 
or twice daily in order to detect any loosening of the plaster. Occa- 
sionally the erysipelatous inflammation extends in diminished intensity 
for a short distance beyond the first line of plaster, but this does not 
last long. This method of treatment is at least harmless, and if future 
experience should prove, as it probab^ will, that it will not succeed in 
arresting the local extension of the disease, it will at least provide an 
efficient protection for the inflamed skin. 

Phlegmonous inflammation and metastatic suppuration should be 
prevented, as far as possible, by the employment of such measures as 
will guard against the formation of suppurating foci in the inflamed skin. 
Bullae should be evacuated as soon as they form by puncturing with an 
aseptic needle, carefully preserving the cuticle as a protection against 
the entrance of pyogenic microbes. Unfiltered air should not reach 
the inflamed skin, and for this purpose it should be covered either with 
an antiseptic, moist compress, or a thick layer of antiseptic cotton. The 
skin is disinfected in advance of the extension of the disease, and is sub- 
sequently protected against additional infection bj T applying a hot, moist 
antiseptic compress, or by covering it with antiseptic absorbent cotton. 
If suppuration take place in the interior of bnllse the cuticle should be 
removed, after which the surface is carefully disinfected by irrigation 
with a germicidal solution, followed by an application with a 10-per-cent. 
solution of chloride of zinc, and further infection prevented bj r an anti- 
septic dressing. If phlegmonous inflammation develop in spite of these 



ERYSIPELOID. 411 

prophylactic measures, early and free incisions are made, free drainage 
established, and a subsequent treatment followed out appropriate for 
phlegmonous inflammation not complicated by erysipelas. Gangrene of 
the skin is to be treated by applying a hot antiseptic compress until the 
dead tissue is eliminated, when the defect is replaced by skin-grafting. 
Internal medication has even been less satisfactory than the local meas- 
ures in the treatment of erysipelas. During the febrile stage the admin- 
istration of the tincture of ferric chloride and the mineral acids does 
more harm than good. If the temperature is high, a daily antipyretic 
dose of quinine is indicated, and exerts a favorable influence upon the 
local process and the general condition of the patient. If the patient 
is restless a full dose of Dover's powder should be given at bed-time. 
Symptoms of prostration are met early by the use of a substantial wine 
or some other alcoholic stimulant. 

Symptoms of collapse are treated by administering internally In- 
grains of camphor every hour, or the same amount of the drug is 
dissolved in oil of sweet almonds and injected subcutaneously every 
half-hour or hour until symptoms of intoxication, delirium, and reduc- 
tion of the pulse to 50 or 55 beats per minute are produced. The cam- 
phor treatment in grave cases of erysipelas was introduced by Pirogoff, 
and has yielded excellent results when the threatening symptoms point 
to an enfeebled heart. 

ERYSIPELOID. 

A new form of infective dermatitis, which in many respects resembles 
erysipelas, has been recently described b} r Rosenbach under the name of 
" erysipeloid." It attacks usually the fingers and exposed portion of the 
hand, and is most frequently met with in persons who handle game or 
dead animals, as cooks, butchers, fish-dealers, and tanners. The affection 
starts from some minute abrasion of the skin as a bluish-red infiltration, 
which slowly advances in an upward direction. The inflamed parts 
are the seat of a burning, smarting sensation. While the skin at the 
point of infection returns to its natural condition and color, the zone of 
infiltration becomes larger, as it continues to spread until the disease 
appears to exhaust itself in the course of from one to three weeks. The 
infectious material which produces this disease is contained in decom- 
posing animal substances. Infection may take in any abraded part of 
the bodv which comes in contact with material containing the virus. The 
temperature remains normal, and the general health is not affected. The 
inflammation travels very slowly, so that if infection take place in the 
tip of a finger it reaches the metacarpophalangeal joint in about eight 
days, and during the second week it spreads over the back of the hand, 
from where an adjacent finger may become affected, the extension then 



412 PRINCIPLES OF SURGERY. 

taking a direction opposite to the lymph-current. Repeated experiments 
to obtain a pure culture of the microbe failed, until in November, 1886, 
the author succeeded in cultivating it upon gelatin from a case in which 
the disease could be traced to infection from old cheese. 

The author injected a pure culture under the skin of his own arm 
at three different points. After forty-eight hours he experienced a 
smarting, burning sensation at the points of injection ; at the same time 
a circumscribed redness appeared around each puncture, which soon be- 
came confluent. On the fifth day each puncture was surrounded hy a 
zone of inflammation the size of a silver dollar, somewhat elevated above 
the niveau of the surrounding skin. While the centre of this red patch 
became pale, the zone of inflammation continued to enlarge. In the 
inflamed skin the capillaiy vessels could be seen dilated, — a condition 
of the circulation which imparted to the tissues an arterial hue with a 
slight tinge of brown, while inside of the zone the color was a livid 
brown. In the skin which had returned to its normal pale color slight 
suggillations appeared, as though some of the red blood-corpuscles in the 
tissues had been destroyed during the progress of the disease. The in- 
flammation appeared to have completely subsided on the eighth day, when 
the smarting sensation returned, and a new zone appeared around the 
old one. On the tenth day the area measured in its transverse diameter 
24 centimetres, and in the parallel direction of the arm 18 centimetres. 

After this the affection disappeared permanently. During all this 
time the general health remained unimpaired, and the temperature 
varied from 36.8° to 31.2° C. A microscopical examination of the pure 
culture showed that it was composed of swarms and heaps of irregular, 
round, and elongated bodies somewhat larger in size than the staphylo- 
coccus. The author first believed that these bodies were cocci, but later 
he saw a net-work of intertwining threads, and decided that they were 
thread-forming microbes. In old cultures the threads were very abun- 
dant, and arranged in every possible way'and direction. These threads 
appeared as though branches were given off, but on closer examination 
it could be seen that no organic connection existed between them. Ter- 
minal spores at the tips of the threads were numerous and could not be 
stained. Neither the microbes nor the threads manifested motile power 
in the culture, or w r hen suspended in water ; a gelatin culture became 
visible on the fourth day as a delicate cloud, which increased in size 
very slowly at a temperature of 20° C. The older cultures change into a 
brownish-gray color, and then resemble the culture of the bacillus of 
septicaemia in mice. In cultures 4 months old the growth was not 
entirely suspended. The author, as yet, has not given a name to this 
microbe, but believes, on botanical grounds, that it belongs to the " clado- 



ERYSIPELOID. 413 

thrix " variety of microorganisms. He wished to ascertain the action 
of this microbe on lupus, but in several cases in which it was tried the 
inoculations failed. Erysipeloid is a harmless form of infection, and 
subsides spontaneously in the course of two or three weeks. I have 
seen a number of cases in persons handling fish and game, where the 
affection started in one of the fingers, extended slowly as far as the dor- 
sum of the hand, and then gradually invaded an adjacent finger and the 
back of the hand as far as the wrist. In the cases that have come under 
my observation the inflammation never extended beyond the wrist. The 
disease is self-limited, and its local extension is not arrested by any 
topical applications. 



CHAPTER XVI. 

Tetanus. 

The wound-infective diseases in which the microbes or their toxins 
act upon the central nervous system are represented by tetanus and 
hydrophobia. The specific microbes which are the cause of these dis- 
eases produce no gross pathological changes in the brain or spinal cord, 
but the minute tissue changes cause a central irritation, which is mani- 
fested by spasm of certain definite muscular groups. Tetanus is an 
infective disease in which the specific microbic cause exerts its patho- 
genic action on the central nervous system, and which is clinically char- 
acterized by spasm and rigidity of definite muscular groups. 

BACTERIOLOGICAL STUDIES. 

The classification of tetanus with the infectious diseases is of recent 
date, but the infectious nature of the disease was well known and estab- 
lished before the discovery of the bacillus tetani. In 1859 Betoli related 
the case of a bull that died of tetanus after castration. Several slaves 
ate some of the flesh of the dead animal, and of these 3 were (in a few 
days) seized with tetanus and 2 of them died. He adds, further, that 
in Brazil, where this occurred, the flesh of animals dead of tetanus is 
generally regarded as capable of transmitting the disease. In 18T0 
Anger reported a case in which a horse had spontaneous tetanus, after 
which 3 puppies which had been in the same stable were also affected. 
Larger, in 1853, saw a woman who had a fall while cleaning a farm-yard, 
causing a slight wound of the elbow. Four weeks later she was seized 
with tetanus, and on investigation it was found that a horse affected 
with that disease had been in a stable opening into the yard where she 
fell. He also mentions another circumstance which strongly points to 
the infectious nature of tetanus. In a small village, where tetanus was 
previously unknown, 5 cases appeared in eighteen months under quite 
different climatic conditions. Of these, 1 had been taken to a hospital, 
after which 2 others in the same ward became affected with the disease. 
In 1884 Carle and Rattone produced the disease artificially in animals by 
inoculations with pus from tetanic patients. Nearly at the same time 
the real microbic cause of tetanus was discovered by Nicolaier and 
Rosenbach. Nicolaier showed the exogenous origin of the disease by 
finding a bacillus in earth which produced tetanus in animals when 
injected into the tissues. Rosenbach found the same bacillus in the pus 
of a patient suffering from traumatic tetanus. The identity of the 
(414) 



BACTERIOLOGICAL STUDIES. 



415 



bacillus of tetanus with Nicolaier's bacillus-of-eartk tetanus was demon- 
strated in Koch's laboratory, April 10, 1887. 

Bacillus Tetani. — Rosenbach describes the bacillus as an anaerobic 
microorganism which presents a bristly appearance, with a spore at one 
of its extremities which gives it the resemblance to a pin or drum-stick. 

According to Kitasato the bacilli produce spores in thirty hours in 
cultures kept at a temperature of the body. They possess great resistance 
to heat, as they have been found active after an exposure of one hour to 
80° C. of moist heat, but they are destroyed by placing them in a steril- 
izer heated to 100° C. for five minutes. The bacillus has been found in 
different kinds of surface soil and in street-dust. In man it has been 
found in tetanic patients in 
the wound-secretions, in the 
nerves leading from the seat 
of infection, and in the 
spinal cord. 

Cultivation . — Rosenbach 
found it impossible to obtain 
a pure culture ; although he 
resorted to fractional culti- 
vation, it was found that the 
last culture was still con- 
taminated by one or more ad- 
ditional microbes. Fluegge 
claimed to have obtained a 
pure cultivation by heating 
for five minutes the mixed 
culture to 100° C, but 
after this procedure the 
bacillus was incapable of 

further propagation. After many trials it was found that sterilized 
solid blood-serum was the best soil for the propagation of the bacillus 
outside of the body. Both Nicolaier and Rosenbach observed the 
anaerobic nature of the bacillus, as it was found impossible to obtain 
a culture by streak inoculations, or in any other manner by which oxygen 
could not be excluded. The culture appeared slowly, as a delicate, 
whitish-gray film, in the track of the stab inoculation, below the surface 
of the culture substance. By a long series of cultures Rosenbach 
finally succeeded in eliminating all other microbes with the exception of 
a bacillus of putrefaction. The growth of the bacillus takes place most 
readily at an equable temperature of 37° C. (98.6° F.),and becomes first 
visible about the third day in the depths of the culture media. Kitasato 




Fig. 140.— Tetanus Bacii/li. Spore-bearing Rods 
prom an Agar Culture. Mounted Prepa- 
rations, Stained with Fuchsin. x 1000. 
{Fr'ankel-Pfeiffer. ) 



416 



PRINCIPLES OF SURGERY. 




has finally succeeded in obtaining a pure culture of the bacillus of 
tetanus from pus taken from a patient suffering from this disease. As 
the bacillus will only grow where atmospheric air can be excluded, he 
exposed his cultures to hydrogen gas with complete exclusion of oxygen. 
Mixed cultures, which had been kept for several days in the incubator, 
were then exposed for half an hour to a temperature of 80° C. Further 
growth was then obtained upon plate cultures in closed glass vessels 

filled with hydrogen gas. By heating the mixed 
culture to 80° C. he destroyed all microbes 
with the exception of the bacillus of tetanus, 
which, later, was cultivated upon solid nutrient 
media in an atmosphere of l^drogen gas. 
At a temperature of 18° to 20° C. a visible 
culture appeared at the end of a week. If the 
temperature was increased to blood-heat the 
bacilli and spores developed more rapidly. 

Inoculation Experiments. — Nicolaier pro- 
duced tetanus in rabbits and mice, experiment- 
ally, by inoculations with different kinds of sur- 
face soil. Out of 140 experiments in 69 a disease 
was produced identical with tetanus in man. In 
the pus, at the point of inoculation, bacilli and 
micrococci were constantly found. Among the 
bacilli one form was constantly present ; this 
bacillus resembled in appearance and culture 
the bacillus of septicaemia in mice, but was more 
slender. This bacillus was found in isolated 
places in the connective tissue, but could not be 
found in the muscles, nerves, and blood. Earth 
sterilized by exposing it to a high temperature 
for an hour proved harmless, showing con- 
clusively that the contagium of tetanus had 
been destroyed. Inoculations with pus taken 
from tetanic animals were most successful. 
Inoculations with mixed cultures grown in solidified blood-serum 
yielded positive results. 

Rosenbach made his experiments with mixed cultures grown from 
pus taken from the line of demarcation of a case of frost gangrene in 
a patient who had died of tetanus. The inoculations proved successful. 
Bonome reports the case of a man suffering from paraplegia, the result 
of disease of the spine in the dorsal region, complicated by an exten- 
sive sacral decubitus, the seat of phlegmonous inflammation, who was 



|i : -=v 




Fig. 141.— Culture of Ba- 
cillus Tetani in 
Nutrient Gelatin. 
(Kitasato. ) 



BACTERIOLOGICAL STUDIES. 417 

suddenly attacked by tetanus, which proved fatal in two days. One hour 
after death a small portion of the infiltrated tissue around the gangre- 
nous part was removed, and after reducing it to a fine pulp by tritura- 
tion he injected it under the skin of a rabbit. Twenty-two hours after 
inoculation the animal died with well-marked symptoms of tetanus. The 
products of inflammation from the point of injection thrown into the 
subcutaneous tissue of other animals produced the disease, while intra- 
venous injections proved harmless. The gravity of sj^mptoms following 
subcutaneous injections was commensurate with the quantity of fluid 
injected. Guinea-pigs proved less susceptible to infection than rabbits. 
In the pus taken from the dead tissue he found, besides the usual 
pus-microbes, a bacillus which resembled in every respect the one de- 
scribed by Nicolaier and Rosenbach. Hochsinger made his observations 
on a case of tetanus which proved fatal on the fifth day. The day before 
the patient died blood was abstracted from a vein, under strict antiseptic 
precautions, for microscopical and bacteriological study. No micro- 
organisms could be found in it. With the greatest care sterilized, solid 
blood-serum was inoculated with the blood, by making, with the needle, 
both superficial streaks and deep punctures. The nutrient medium was 
kept at a temperature of 37° C. (98.6° F.). On the third day a white, 
cloudy streak marked the direction of the deep punctures, while the 
superficial plant remained sterile. On the third cla}^ a portion of the 
culture was removed and stained with aniline gentian, and the character- 
istic bacillus was found. A large rabbit was infected by injecting blood 
obtained from the patient during life. The blood was diluted with 
sterilized water, and a sj'ringeful of this mixture was injected under the 
skin in the iliac region, and half of this quantity under the skin of the 
left thigh. The next day the animal was quite ill and unable to use the 
left hind-leg, which was dragged along in walking. At this time great 
nervous excitability was observed, the exaggerated reflex symptoms 
being especially well marked in the posterior extremities, which, on the 
slightest touch, were thrown into clonic spasm. On the following day 
the animal was found dead. A few hours before death well-marked symp- 
toms of tetanus developed. Injections of blood from this animal pro- 
duced no results in other rabbits, and culture experiments were equally 
fruitless. A syringeful of inspissated blood of the patient, kept for three 
weeks, thrown under the skin of a white mouse, was followed by a fatal 
attack of tetanus, while a second animal inoculated in a similar manner 
with one-half of this quantity remained perfectly well. 

Fluegge had before observed that by injecting blood from animals 
rendered tetanic by inoculation it was necessary to use a large quantity 
in order to reproduce the disease in other animals, and even by doing so 

27 



418 PRINCIPLES OF SURGERY. 

the result was not always satisfactory. It appears that the blood of tet- 
anic patients possesses greater toxic properties than the blood of animals 
suffering from the same disease. Hochsinger also made inoculations 
with the mixed cultures. A syringeful of a liquid culture was injected 
into the subcutaneous tissue of a medium-sized rabbit. The next day 
the reflexes were increased, respiration more rapid, and the animal 
appeared otherwise quite sick. On the third day the posterior extremi- 
ties were stiff, the animal dragging them in walking; refhx irritability 
enormousl} T exaggerated. On the fifth da}^ the animal dbd, with well- 
marked symptoms of tetanus. A number of similar successful experi- 
ments are reported by the same author. In rabbits, Fluegge estimated 
the stage of incubation at from three to five days, and the duration of 
of the disease, from the time the first s} r mptoms were noticed to the fatal 
termination, from five to seven da} T s. 

Beumer gives an accurate and able description of his studies in 2 
cases of tetanus. The first case occurred in a mechanic, who injured 
himself under the nail of the right middle finger with a splinter of wood. 
Eight days after the injury, the patient having had but slight pain in the 
finger, pains appeared in the neck and muscles of the back. The next 
morning spasms of the muscles of the chest, abdomen, and jaw developed. 
These attacks occurred at intervals of an hour and a half. Four da}'s 
later the lower extremities were affected, also the upper, but in a less 
degree. An incision was made and the foreign body removed, which 
was followed by the escape of a drop of pus ; death on the fourth day. 
The second case was a bo}^ 6 J } T ears old, who was brought into the clinic 
with well-marked symptoms of tetanus, and who lived only a few hours 
after his admission. The author obtained some of the dust and splinters 
of wood from the place where the mechanic had injured himself, and in- 
serted small particles under the skin of mice and rabbits. In all experi- 
ments the animals were attacked with tetanus in from two to three da}'S 
after inoculation, and during the third or fourth. The spasms were 
always noticed first in the muscles nearest the point of inoculation. A 
fragment of tissue from the sole of the foot was taken from the bo}^, and 
small particles of it inserted into the subcutaneous tissue of 6 mice. 
In all of these S3 T mptoms of tetanus appeared after two days, developing 
gradually into general convulsions and death. 

The same results were obtained in mice and rabbits bj' inoculations 
of particles of dust taken from the spot where the boy sustained the 
injury. The same author also made numerous experiments with different 
kinds of earth. Of 10 experiments with soil taken from the ocean- 
beach, tetanus followed in only 2. On the other hand, of 10 inocu- 
lations with garden-earth and street-dust, all proved successful but 1. 



BACTERIOLOGICAL STUDIES. 419 

Of the greatest scientific and practical interest are the observations 
made by Bononie, in reference to the causation of tetanus by infection 
with earth containing the bacillus discovered by Nicolaier. He had an 
opportunity to observe a number of cases of tetanus after the earth- 
quake at Bajardo. Of the 70 persons injured in the ruins of the 
church, 7 were attacked by tetanus. From bacteriological investi- 
gations in connection with these cases, he came to the same conclusions 
in regard to the cause of the disease as Nicolaier, Rosenbach, Fluegge, 
and Beumer before him. Of special importance is the observation made 
by him, that the secretions from the wounds and the exudation from the 
part, the seat of tetanic convulsions, when dried and preserved between 
two sterilized watch-glasses, retained their virulent properties for at least 
four months. All animals inoculated with dust from the debris in the 
interior of the church were attacked with tetanus. Control experiments 
with dust from the ruins at Diano-Marina were alwa} 7 s followed by nega- 
tive results. Of the many persons injured during the same earthquake 
at this place, not one was attacked by tetanus. 

Ohlmiiller and Groldschmidt made a thorough bacteriological inves- 
tigation of a case of tetanus following complicated fracture of the right 
thumb. The disease appeared the day following the injury, and proved 
fatal in seventeen hours. Soon after death inoculation experiments were 
made with blood taken from the heart and spleen, and pus from the seat 
of fracture. The cultures were grown in solid blood-serum kept at a 
temperature of 38° C, (100.7° F.). The tubes containing blood from 
the heart and spleen remained sterile, but the nutrient media infected 
with pus showed signs of growth. The bacilli which were detected re- 
sembled those of mouse-septicaemia, only somewhat larger in size. In 
addition to these microbes streptococci and a thick bacillus were found. 
Two mice were inoculated with this mixed culture. Twelve hours after 
infection tetanus developed, followed by death in seventeen hours. The 
spasms commenced in the tail, extended to the posterior extremities, and 
then gradually advanced in a forward direction. From these animals 
blood-serum was taken, with which other mice were infected. Again, 
tetanus was produced, and successful cultivations were made of 2 mice 
of equal size and age; 1, which received one portion of a culture, died 
of tetanus on the ninth day, while the other, which received a dose three 
times as large, died on the third da3 T . Of 3 cases of tetanus which 
recently came under the observation of Lumniczer, he was able to 
demonstrate the microbic origin in 1. In this case the attack followed 
a gunshot injury. After the disease had developed fragments of hemp 
were removed from the canal made b} T the bullet, and in them the char- 
acteristic bacillus was found. Cultures were made to the tenth genera- 



420 PRINCIPLES OF SURGERY. 

tion, and with them animals were inoculated, and tetanus was invariably 
produced. Pus taken from abscesses produced at the point of inocula- 
tion contained the bacillus, and inoculation experiments made with it 
yielded positive results. Cultures made from the blood or organs of the 
tetanic animals remained sterile. Inoculations with blood from these 
animals proved harmless. 

Kitasato experimented with a pure culture of the bacillus of tetanus 
on mice, rats, guinea-pigs, and rabbits, and never failed in producing the 
disease, provided a sufficiently large dose of the culture was adminis- 
tered. In mice the disease appeared, without exception, twenty-four 
hours after the inoculation, and proved fatal in two to three days. The 
tetanic convulsions were first alwa}^s local, appearing first in the muscles 
nearest the point of inoculation, and becoming gradually more diffuse. 
He was unable to find the bacillus at the seat of inoculation, the blood, 
or in any of the internal organs. He is of the opinion that if tetanus is 
produced by inoculation with a pure culture the bacilli do not remain 
in the body for any length of time, but are rapidly eliminated. The ex- 
periments and clinical observations which have just been quoted furnish 
conclusive proof that tetanus is a microbic disease, and that the bacillus 
of tetanus discovered by Nicolaier and Rosenbach is its essential cause. 
Whether cultivations from chronic cases of tetanus can produce an acute 
and rapidly-fatal attack in animals remains to be determined. In this 
direction I have recently made an observation which, if not convincing, 
is at least very suggestive. A boy 15 years of age, previously in good 
health, was attacked with acute osteonryelitis in the lower extremity of 
the femur. The surgeon in attendance trephined the bone just above 
the external condyle during the first few da} T s,and before an abscess had 
formed in the soft parts. A few days after the operation trismus set in, 
followed by typical chronic tetanus. Six weeks later the patient entered 
the Milwaukee Hospital, and was placed under my charge. At this time 
the patient had become emaciated to a skeleton. 

Trismus and opisthotonus were well marked, and the lower ex- 
tremities were rigid and fixed in the extended position. The slightest 
touch, or a draught of air in the room, would bring on intense convul- 
sive attacks for several minutes, attended by excruciating pain. Pro- 
fuse fetid discharge at the site of operation ; pulse, 140 ; temperature, from 
99° to 101° F. (37.3° to 38.8° C). Believing that the primary infection 
had taken place through the operation wound, and that the osteomyelitic 
products served the purpose of a nutrient medium for the bacillus tetani, 
I determined to operate in spite of the grave symptoms. As the spinal 
cord at this stage of the disease was necessarily the seat of the intense 
congestion, I resorted to chloroform as an anaesthetic in preference to 



BACTERIOLOGICAL STUDIES. 421 

ether. The usual operation for necrosis of the lower end of the femur 
was made, and a large triangular sequestrum removed from the lower and 
posterior aspect of the bone. The involucrum was defective, and its 
inner surface was found lined with a thick layer of nabb} T granulations. 
Gelatin tubes were inoculated with blood, pus, and granulation tissue. 
The tube inoculated with blood remained sterile, while the two remaining 
tubes showed a copious growth of staphylococcus pyogenes albus, which 
rapidly liquefied the gelatin. A portion of the granulation tissue was 
disinfected with a weak solution of carbolic acid, dried between la} T ers 
of antiseptic gauze, and inserted under the skin of a full-grown, large 
rabbit. No suppuration followed, and the animal remained perfectly 
well for six weeks, when both posterior extremities became rigid and 
could not be used in walking. The next day tetanic convulsions affect- 
ing the muscles of the back and all the limbs appeared, and on the fourth 
day death supervened. 

The interesting features in this case are that the patient recovered 
from the tetanus after a long illness, extending over three months ; that 
marked improvement followed the operation, which had for its object 
thorough disinfection of the infection-atrium; and that the inoculation 
with granulation tissue in the rabbit was followed by an acute attack of 
tetanus after an incubation stage extending over six weeks. In the ex- 
periments related above the animals were inoculated with cultures, earth, 
other infected foreign substances, fragments of diseased tissue, or with 
wound-secretions from tetanic patients ; the stage of incubation r.«rely 
extended over two or three da} T s, and often the spasms appeared in 
eighteen to twenty-four hours, and the disease produced death in from 
two hours to three days. 

The same question has been raised in connection with the pathogenic 
action of the bacillus of tetanus as with pus-microbes: Is the disease 
of which it is the specific cause due to the presence of the microbe, or 
the toxins which it elaborates in the tissues ? 

Toxins of the Bacillus Tetani. — Brieger, b}^ his indefatigable labors, 
has demonstrated beyond all doubt that the toxins of the bacillus 
of tetanus cause tetanic convulsions. Stiychnia in toxic doses produces 
a condition which, so far as the muscular spasms are concerned, closely 
resembles tetanus. If this and other drugs belonging to the same 
group can act upon the spinal cord in such a manner as to cause spasms 
and muscular rigidit}', we should, a priori, expect that if the microbe 
of tetanus produce toxins in the tissues these might produce the same 
effect on the cord, and that the ' symptoms are produced by them and 
not b}' the direct action of the microbe. Nearly all authorities are 
agreed that the bacilli present in the blood of tetanic patients are 



422 PRINCIPLES OF SURGERY. 

few, and in animals in which the disease was produced artificially the 
blood was often found sterile. More microbes have been found at the 
seat of primary infection, and in the tissues between it and the spinal 
cord, than in the blood itself, — another proof that the direct cause of the 
disease is the product of the microbes, and not the microbes themselves. 
Brieger has succeeded in isolating four toxic substances from mixed 
cultures of the tetanus bacillus in sterilized emulsion of meat. The 
first, tetanin^ in doses of a few milligrammes, administered subcutaneously 
in mice, produced the characteristic sj^mptoms of tetanus. The second, 
tetanotoxin, causes, first, tremors; later, paralysis and convulsions. The 
third, muriate of toxin, has not been designated b} 7 a special name ; it 
produces also well-marked symptoms of tetanus, but, besides, excites the 
salivaiy and lachrymal glands to increased functional activity. The 
last, spasmotoxin, produces severe clonic and tonic spasms, which 
prostrate the animal at once. Besides meat-emulsion, the contused 
brain-substance from horses and cattle was used ; also cows' milk mixed 
with carbonate of lime. It seems that the culture substance determined, 
to a certain extent, the kind of toxin which was produced; thus, in 
cultures grown in brain-substance, besides the tetanin, tetanotoxin was 
found in greatest abundance ; old cultures, in which the tetanus bacilli 
were dead, produced none of these toxic substances. 

The same author has very recently been successful in isolating 
tetanin from the amputated arm of a patient the subject of tetanus. 
The disease had developed a few days after a severe crushing injury of 
the hand and forearm. The first symptoms manifested themselves in the 
morning, and at 12 o'clock (noon) the operation was performed ; at 
5 o'clock on the same daj 7 the patient expired suddenly during one 
of the tetanic convulsions. The bacilli of tetanus were found in the 
serum taken from the cedematous portion of the forearm, in connection 
with other bacilli of different length, — staphylococci and streptococci. 
Serum containing these microbes injected under the skin of mice, 
guinea-pigs, and rabbits invariably produced tetanus. On the other 
hand, a dog treated in the same manner, as well as after injections of 
tetanin, remained well. A horse inoculated with a culture of bacilli in 
meat-emulsion showed no symptoms of tetanus, but an abscess formed 
at the point of inoculation. The infiltrated tissues of the amputated 
arm planted on sterilized meat-emulsion, solid blood-serum, and emulsion 
made of the flesh of fish, yielded, besides ammonia, only tetanin ; no 
trace of tetanotoxin, spasmotoxin, nor the unnamed toxin which could 
be obtained from Bosenbach's bacillus. A moderate dose of tetanin 
injected into the subcutaneous tissue of a horse produced muscular 
contractions which lasted for a considerable length of time, but the 



BACTERIOLOGICAL STUDIES. 423 

characteristic symptoms of tetanus, as witnessed in horses suffering from 
tetanus, did not appear. 

Pestana obtained the toxin of the tetanus bacillus from a pure 
culture in bouillon in the absence of air, which was preserved at a tem- 
perature of 38° C. for nineteen days, and was then filtered through a 
porcelain filter. Careful examination of the filtrate showed that it con- 
tained no bacilli. Experiments were made on guinea-pigs and mice; the 
guinea-pigs were used for the direct injection of the toxin obtained from 
the cultures ; the mice were employed to determine the toxicity of the 
blood and different organs of the guinea-pigs which received the filtrate. 
One drop of toxin injected under the skin of the thigh of a guinea-pig 
caused tetanus at the end of twelve hours and death in twenty-four hours. 
One-twentieth of a drop produced in mice all the symptoms of the dis- 
ease in eighteen hours and death in thirty-eight hours. In order to 
study the diffusion of the toxin in the body inoculations were made at 
variable periods after injection of the toxin and with the blood and dif- 
ferent organs of the infected animal. In the first series of experiments 
1 drops of toxin were injected under the skin in the sacral region of a 
guinea-pig. As soon as symptoms of tetanus showed themselves the 
animal was killed by cutting the carotid. The blood obtained was in- 
jected in different quantities under the skin of a number of mice. A 
trituration of the different internal organs and muscles, each made sepa- 
rately and diluted with a saline solution, was injected in another set of 
mice. Tetanus and death were uniformly produced in the mice injected 
with 15 or more drops of blood, and also in those who had been inocu- 
lated with the emulsion of the muscles from the region of injection. The 
other animals remained in perfect health. In the second series the 
guinea-pig was killed in a similar manner after the tetanic convulsions had 
become general. One cubic centimetre of blood and half this quantity 
of the emulsion of a small portion of the liver produced tetanus, causing 
death of the mice at the end of forty-eight hours with all the symptoms 
of the disease. The triturations prepared from the other organs and tissues 
produced no effect except that from the muscles of the region injected, 
which always gave positive results. In the third set of experiments the 
injections were made after the death of the guinea-pig with emulsions of 
the organs, of the blood, and of clots found in the heart, and in these 
only the liver contained enough toxin to produce tetanus. These exper- 
iments tend to prove that the toxin rapidly enters the blood, and that 
later it accumulates in the lungs, spleen, kidney, but principally the liver, 
and that it is not eliminated to any appreciable extent by the urine. 
Notwithstanding the striking predominance of neuro-muscular phenom- 
ena in tetanus, the presence of toxin in nervous and muscular tissue 



424 PRINCIPLES OF SURGERY. 

cannot be shown ; all the experiments made with these tissues yielded 
negative results. 

ETIOLOGY. 

The clinical and experimental researches just quoted demonstrate 
that the bacillus tetani is found in the wound-secretions, the tissues, 
and, in some instances, in the blood of tetanic patients, and that tetanus 
in animals can be produced artificially by injections of wound-secretions 
of tetanic patients, or by using mixed or pure cultures, — facts which 
have firmly established the microbic nature of the disease. The essen- 
tial cause of tetanus Is the bacillus first discovered by Nicolaier in 
earth, and by Rosenbach in the wound-secretion of a tetanic patient. 

Period of Incubation. — The period of incubation, both in man and 
in animals, appears to be extremely variable, in some instances lasting 
only twenty-four hours, while in others weeks may elapse between the 
time of infection and the first manifestations of the disease. This may 
depend on one of three things: 1. The number of bacilli introduced may 
be so small that a much longer time is necessary before active symptoms 
are produced than if a larger quantity had been introduced, as Watson- 
Cheyne has shown that in animals the injection of a limited number of 
the bacilli of tetanus produced no symptoms. 2. The location of the 
infection-atrium and anatomical characteristics of the tissues surround- 
ing it may influence the time which is necessar}' to develop the disease. 
3. Brieger's investigations have shown that tetanic convulsions in animals 
are produced by injections of tetanin, — one of the toxic toxins derived 
from cultures of the bacillus of tetanus; and it is more than probable 
that the active symptoms of tetanus in man are due not to the presence 
in the tissues of the bacillus, but to the toxic action of the ptomaines on 
the spinal cord ; so that the duration of the period of incubation is fur- 
ther modified by the capacity of the infected tissues to yield the different 
ptomaines. The degree of virulence of the bacillus of tetanus must cer- 
tainly play an important part, not only in determining the duration of 
the incubation stage, but also the gravity of the disease. 

Specific Microbic Cause. — There can be no doubt that both the 
acute and chronic forms of tetanus are caused by the same microbe, and 
that the clinical difference depends upon the degree of virulence of the 
primar}^ cause, on the one hand, and the degree of susceptibilty of the 
individuals to tetanic infection, on the other. 

In reference to the susceptibilit}' to infection with the bacillus of 
tetanus, it has been shown by reliable statistics that the colored races, 
under the same conditions, are attacked more frequently by tetanus than 
the Caucasians. Inoculation experiments have shown that the greatest 



ETIOLOGY. 425 

difference exists among different kinds of animals in this respect, and 
there is no reason why the same difference of susceptibility to this dis- 
ease should not exist in the human species. As the natural habitat of 
the bacillus of tetanus is the soil, we can readily understand that the 
disease should occur more frequently in some localities than in others, 
and why it is more prevalent in southern than northern climates. The 
excretions and cadavers of tetanic animals may infect the soil, where, 
under favorable conditions, the bacillus may multiply, and in this manner 
a greater or less portion of the surface soil becomes a nutrient medium, 
in which an immense culture is developed from which new cases can 
become infected. A warm climate is more favorable for the unlimited 
reproduction of the bacillus in the soil than northern countries ; hence 
the greater prevalence of this disease in the tropics. 

Infection -Atrium. — As the bacillus of tetanus is the essential 
cause of the disease, the remaining causes are accidental conditions, 
which result in the formation of an infection-atrium. We have no evi- 
dence that the bacillus can enter the tissues through an intact mucous 
membrane or unbroken skin. Idiopathic tetanus, so called, is a clinical 
form of tetanus where even the most thorough examination reveals no 
infection-atrium. As in cases of erysipelas, under similar circumstances, 
the local lesion may have been so insignificant as not to have attracted 
the patient's attention, or if he was cognizant of it at the time it may 
have completely disappeared at the time the first symptoms developed 
themselves. 

In trismus sive tetanus neonatorum infection undoubtedly takes 
place through the umbilicus. In a case of this kind Beumer found the 
tetanus bacillus in the tissues. There is hardly an operation, capital 
and minor, which has not furnished its quota to the long list of tetanic 
patients. It has been observed most frequent!}' after amputation, castra- 
tion, and extirpation of the tigroid gland. 

Weiss reported 13 cases of tetanus occurring after extirpation of 
the thyroid gland. He attributes the frequency with which this disease 
follows the removal of this organ to irritation of peripheral nerves 
induced by the numerous ligatures. Middeldorpf observed paralysis of 
the facial nerve in some of these cases, — a circumstance which would 
indicate a central origin of the disease. In 53 total extirpations of the 
thyroid gland for goitre made by Billroth, tetanus followed in 12 cases, 
while no cases occurred in 109 partial operations. Two cases became 
chronic, in which the disease, at the time von Eiselsberg made the report, 
had lasted for six and nine years. In 7 cases there was, besides the 
ordinaiy characteristic S3 T mptoms, an involvement of the muscles of the 
face, neck, larynx, diaphragm, and abdomen ; so that djspnoea and even 



426 PRINCIPLES OF SURGERY. 

loss of consciousness occurred. In the fatal cases death occurred in 
from three to thirtj 7 days, and in 1 case after seven months. 

Quite a number of cases have been reported during the last few 
years where it occurred after abdominal section. Tetanus occurring 
after an operation must be the result of infection through the operation 
wound with the specific bacillus, which, without exception, takes place 
by contact. As the bacillus of tetanus is not a pyogenic microbe, it is 
not necessaiy that a wound through which infection has occurred should 
suppurate. When suppuration takes place it is in consequence of a 
mixed infection. It is a well-known clinical fact that punctured, lacer- 
ated, and gunshot wounds of the hands and feet are most liable to be 
followed b} T tetanus. Before it was known that tetanus is a microbic 
disease, the frequency with which this disease complicated such injuries 
was explained upon the ground that the part injured was abundantly 
supplied with sensitive nerves, and that the irritation caused by the 
injury proA r oked the disease. As thousands of operations upon the 
hands and feet performed under antiseptic precautions have not resulted 
in a single instance in tetanus, this explanation is no longer tenable. 
The antiseptic treatment of wounds has greatly diminished the fre- 
quency of tetanus as a complication of operation wounds. Expe- 
rience has shown that the same treatment which prevents suppuration 
and other wound-infective diseases has also diminished the frequency 
of tetanus. Wounds of the hands and feet are so often followed by 
tetanus, because, in the first place, the implement or substance which 
inflicts the wound is frequently contaminated with infected earth or 
dust, and, in the second place, such wounds are often neglected and 
exposed to subsequent infection from the same sources ; and, lastly , 
infected foreign bodies are often allowed to remain in the wound. In 
a number of instances animals were successfully infected by inserting 
under the skin particles of foreign bodies removed from tetanic patients. 
Wounds of the hands and feet are no more liable to cause tetanus than 
wounds in any other part of the body, provided they are not exposed to 
greater risk of infection. Infection through the uterus after abortion 
and during childbed has been repeatedly observed. 

Gautier has collected ?4 cases of tetanus, 36 following abortion and 
38 following confinement. Autopsies were made in 15 cases ; 3 pre- 
sented, on microscopical examination of the brain and cord, no appreci- 
able lesion ; in 1 case a retained putrefied placenta was found in the 
uterus ; in 5 suppurative metritis or salpingitis ; in 1 ovarian cyst. 
The other autopsies showed hyperemia of brain, cord, and meningitis ; 
in 1 haemorrhage into the lateral ventricles. Ten patients recovered, — 5 
after abortion, 5 after labor. 



SYMPTOMS AND DIAGNOSIS. 427 

Frost gangrene is especially prone to be followed by tetanus. Of 
3*75 cases of tetanus collected by Thamhayn, the disease followed wounds 
of the fingers and hand in 27 per cent.; of the thigh and leg, 25 per cent.; 
of the toes and foot, 22 per ceut.; of the head, face, and neck, 11 per cent., 
of the arm and forearm, 8 per cent.; and of the trunk, 6 per cent. Of 700 
cases collected by the same author, the disease was known to have fol- 
lowed a trauma in 603. As males are more frequently exposed to injury 
than females, the disease is correspondingly more frequent in that sex. 
The largest number of tetanic patients are found among persons from 
10 to 30 years of age, although no age is entirely exempt. According 
to Larrey, Cullen, and Dupuytren, the disease can be caused, and is 
always aggravated, by drafts of cold air. That the disease is never 
caused by exposure to cold requires no argument ; that drafts of cold 
air aggravate the disease when it exists is unquestionable, as every 
peripheral irritation cannot fail in aggravating the muscular spasms. 

SYMPTOMS AND DIAGNOSIS. 

The toxins of the bacillus of tetanus act upon the brain and the 
spinal cord in a somewhat similar manner as strychnia. If the spinal 
cord is injured strychnia acts only upon the parts supplied with nerves 
from the intact portion of the cord. If the posterior roots of the spinal 
nerves are divided it produces no spasms in toxic doses. If in an animal 
the brain and medulla oblongata are removed the effect of strychnia upon 
the muscles is not impaired. Injection of hydrate of chloral arrests the 
spasm produced by strychnia, and, consequently, chloral must be con- 
sidered as the most efficient antidote to strychnia. Even the most acute 
cases of tetanus begin insidiously. The patient, perhaps, complains of a 
sensation of chilliness and a feeling of soreness about the region of the 
neck, and shooting pains and stiffness in particular muscular groups. 
The first symptom which announces the onset of this dreadful disease 
is difficulty in mastication. The patient discovers, accidentally, that he 
is unable to open the mouth sufficiently to drink or grasp the food. On 
inspection nothing abnormal is found, but on trying to separate the 
teeth the masseter muscle on each side becomes rigid and prominent. 
This spasm of the muscles of mastication is called trismus. It is the 
first group of muscles affected by the central lesion produced bj T the 
toxins of the tetanus bacillus. If other causes of this condition, such 
as inflammatory lesions in the pharynx and the alveoli of the maxillary 
bones, can be excluded, the existence of trismus is almost a pathogno- 
monic symptom of tetanus. The patient next complains of difficult}' in 
swallowing, as the muscles of deglutition become affected. The next 
muscular groups to become involved are the muscles back of the neck 



428 PRINCIPLES OF SURGERY. 

and the extensors of the spine, giving rise to retraction and fixation of 
the head and overextension of the spine, — conditions which, when well 
developed, produce what is called opisthotonos. In well-marked opis- 
thotonos the body rests on the occiput and heels when the patient is in 
the dorsal position. If the body is bent in an opposite direction, from 
contraction and rigidity of the anterior pectoral and abdominal muscles, 
the condition is called emprosthotonos. Contraction of muscles on the 
side of the chest and abdomen gives rise to pleurosthotonos. Orthotonos 
means tonic spasm and rigidity of all the voluntary muscles, — a con- 
dition frequently present in advanced cases of tetanus. The face of 
tetanic patients presents a characteristic mask-like appearance from the 
contraction and rigidity of the facial muscles. The muscular spasms are 
clonic, and are always aggravated by the slightest causes, as walking in 
the room ; touching the bed-clothes or the body of the patient ; drafts of 
air ; sudden, unexpected noises. The affected muscles are rigid from 
tonic contraction, but this state of rigidity is increased by the paroxysmal 
clonic spasms. 

In acute cases the temperature soon rises to 40° to 41° C, and the 
pulse is correspondingly increased in frequency. The temperature curve 
shows but little change during twenty-four hours. The sensorium usu- 
ally remains unaffected throughout the entire course of the disease. As 
the patient finds it difficult to clear the mouth, the profuse salivary se- 
cretion escapes from the mouth. Respiration is impeded in proportion 
to the number of the respiratory muscles affected. In severe cases early 
dyspnoea and cyanosis are present. Special senses remain intact. The 
pain is mostly excruciating, extending from the neck and back in the 
direction of the nerves, leading to the affected muscular groups. The 
pain is always aggravated with the increased convulsive movements, 
resulting from the action of external irritants. 

In consequence of deficient food-supply, the intense pain, and loss 
of sleep, rapid emaciation and loss of strength appear as early and con* 
stant symptoms. Approaching exhaustion is announced by profuse 
clammy perspiration, coldness of the extremities, and a rapid, feeble, and 
intermittent pulse. As soon as the intercostal muscles are affected res- 
piration becomes more and more embarrassed, and when finally the 
diaphragm is thrown into a tonic spasm respirations and pulse cease, 
general cyanosis follows, and death may ensue during the first spasm of 
the diaphragm. Should, however, the patient rally from this attack, lie 
will be almost certain to succumb to the second or third attack. 

Wunderlich has seen the temperature shortly before death rise to 
42° or 43° C, and the same has been observed in animals dying from 
tetanus by Billroth, Fick, and Leyden. A post-mortem rise in tempera- 



CLINICAL FORMS OF TETANUS. 429 

ture to 44.7° C. has been recorded by Wunderlich, and he attributed this 
strange phenomenon to paralysis of the central heat-moderators. In 
chronic tetanus the disease commences very insidiously, and the graver 
symptoms, such as a very high temperature, feeble and intermittent pulse, 
spasm of the intercostal muscle and diaphragm, are absent. The tem- 
perature is normal or only slightly elevated. Trismus is always present, 
to which may be added spasm and rigidity of the muscles of the back 
of the neck and the extensors of the spine. The trismus makes it diffi- 
cult to administer food in sufficient quantity, and, on this account, pro- 
gressive emaciation is one of the prominent features of this form of 
tetanus, as the disease, as a rule, lasts from six to ten weeks. The dis- 
appearance of symptoms is as gradual as their onset. In the differential 
diagnosis it is important to distinguish between tetanus and strychnia 
poisoning, hysteria, catalepsy, hydrophobia, cerebro-spinal meningitis, 
and basilar meningitis. With few exceptions it is possible in tetanus to 
establish the fact of infection, and the clinical history shows that differ- 
ent muscular groups become involved successively in regular order, first 
trismus, then rigidity of the muscles at the back of the neck, and, finally, 
opisthotonos. In acute cases the disease is attended by a continuously 
high temperature. In strychnia poisoning the maximum symptoms, 
opisthotonos or orthotonos, are developed suddenly, as soon as a toxic 
dose of the drug has been absorbed. The convulsive movements in 
hysteria are not limited to any definite muscular groups, and the pulse 
and temperature are normal. The same can be said of catalepsy. In 
hydrophobia, as we shall see subsequently, the spasms are limited to the 
muscles of deglutition, the stage of incubation is longer than in tetanus, 
and infection is always caused by the bite of a rabid animal, usually a dog. 
In cerebro-spinal meningitis muscular spasm and rigidity are limited to 
the extensor muscles of the spine ; so that, even if the disease has caused 
well-marked opisthotonus, trismus is absent. Tubercular meningitis is 
usually ushered in by intense headache, vomiting, and photophobia, and 
if tonic muscular spasms set in they affect the muscles at the back of the 
neck almost exclusively. Trismus is never present. 

CLINICAL FORMS OF TETANUS. 

Acute Tetanus. — The stage of incubation, as a rule, is shorter than 
that which precedes the chronic form of the disease. Trismus develops 
gradually, but after it has once been established the extension of the dis- 
ease to other muscular groups is rapid. A high temperature and rapid, 
feeble pulse are always present. Respiration is mechanically embarrassed 
by the successive implication of the different muscular groups which are 
concerned in the function of respiration, the last one to become affected 



430 PRINCIPLES OF SURGERY. 

being the diaphragm. The disease may prove fatal in twenty-four hours, 
and the duration is seldom prolonged for more than a week. 

Chronic Tetanus. — The disease not only commences insidiously, but 
the symptoms appear gradually and never develop to the same extent as 
in acute tetanus. The most marked feature is trismus, which may be fol- 
lowed by a mild degree of opisthotonos. The muscles of respiration are 
not implicated, and if death result it is from marasmus and exhaustion 
and not from apnoea. The duration of the disease is seldom less than 
six, nor more than ten, weeks. 

Trismus. — Tetanus in which only the muscles of mastication are 
affected is called trismus. With the exception of the infantile form, 
trismus is a chronic and comparatively benign affection. 

Tetanus Neonatorum. — Tetanus occurring in infants during the first 
week after birth is clinically characterized as trismus, and proves fatal 
almost without exception in a few daj-s. Infection takes place through 
the umbilicus before or after separation of tn^, cord. It is a disease 
that occurs much more frequently in tropical than northern climates, 
for reasons which have been heretofore explained. 

Tetanus Hydrophobicus, op Head Tetanus. — This is a form of tetanus 
which was first described by Bernard and Lepine and E. Rose, in 1870. 
In the cases which have been reported it followed head injuries, espe- 
cially wounds of the face. Besides trismus, it is characterized by pa- 
ralysis of the facial nerve on the injured side. Brunner maintains that 
paralysis of the facial nerve, which seems to be a very common symptom on 
the side of the lesion in man, does not occur in experimental tetanus in 
the lower animals ; on the contrary, there is in them invariably facial 
spasm. From his analysis of these results and his study of the recorded 
cases in man Brunner comes to the conclusion that in many cases the 
facial paralysis reported must be the result of faulty observation or else 
an accidental complication not essentially belonging to this form of 
tetanus. He produced typical tetanus by injecting subcutaneous^ 
blood from the longitudinal sinus and fluid taken from the pleural and 
pericardial cavity of a patient who had died of tetanus hydrophobicus. 
During deglutition the muscles which are concerned in this act are 
thrown into spasm, and on this account the disease bears a strong 
resemblance to h}^drophobia. Klemm has collected up to date 24 
reported cases of this disease. Most of them recovered, and in those 
that died the disease passed into the typhoid form of tetanus. 

PROGNOSIS. 

The most important element in prognosis is the type of the disease. 
The more acute the onset and the more intense the symptoms, the greater 



PATHOLOGY AND MORBID ANATOMY. 431 

the immediate danger to life. IT death does not occur within two weeks 
the prospects of an ultimate recoveiy are good. Of 280 cases which 
comprise the Calcutta statistics of this disease 75 per cent, proved fatal. 
This list represents about the average mortality of this disease. The 
greater the excitability of the motor centres of the spinal cord, and the 
more rapid the successive involvement of different muscular groups, the 
greater the danger of an early dissolution. In acute cases death is 
always preceded by great dyspnoea, and death usually occurs during an 
attack of convulsions, in which the intercostal muscles and the diaphragm 
take part. Chronic cases terminate, as a rule, in recovery after an 
illness lasting from six to ten weeks. 

PATHOLOGY AND MORBID ANATOMY. 

The absence of gross pathological changes is characteristic of 
tetanus. The only constant lesion found is an hypersemic condition of 
the medulla oblongata and the spinal cord, to which special attention has 
been called by Leyden, Joffrey, Ranvier, and Robin. As all of the 
peripheral manifestations of the central lesion point to an increased 
excitability of the nervous centre, we would expect that the principal 
lesions are to be found in the gray substance of the cord. In 1857 
Rokitansky described tetanus as an ascending neuritis. He found a 
connective-tissue proliferation, in the form of a semi-fluid, adhesive, 
grayish substance, between the medullary elements of the nerves leading 
from the infected district. In some cases he found extensive destruction 
of the nerve-tubes, and their space occupied by the products of granular 
degeneration, — colloid and am}doid corpuscles. 

Lockhart-Clark and Dickinson found, as the most constant patho- 
logical lesion, inflammatory softening of the gray substance of the cord 
and dilatation of the vessels. Michaud and Benedict found cell prolifera- 
tion into the anterior cornua of the cord and great vascularity. Elischer 
regarded the central lesion as a myelitis with vacuolation in the ganglia- 
cells. Tyson found in two cases destruction of the central canal of the 
cord, with disintegration of the posterior cornua. Aufrecht narrowed 
the morbid anatom}' of tetanus down to atrophy of the anterior horns, 
in the cervical portion of the spinal cord. Schultze was never able to 
discover anjr evidences of n^'elitis. The hyperemia of the cord, which 
is so constantly found, may be the result of a passive congestion; at 
present this cannot be accepted as proof of inflammation, because in 
most cases the anatomical and clinical evidences do not sustain this 
supposition. The view that tetanus is essentially an ascending neuritis, 
as was claimed by Rokitansky, is no longer tenable, since it is not 
supported by the results of recent investigations. It is left for future 



432 PRINCIPLES OF SURGERY. 

research to furnish more reliable information concerning the pathology 
and morbid anatomy of tetanus. At present we can only surmise that 
the toxins of the bacillus act upon the gray matter of the cord, where 
minute lesions are produced, which must account for the clinical mani- 
festations of the disease. 

TREATMENT. 

The prophylactic treatment of tetanus has in view the prevention of 
infection by the usual antiseptic precautions in the treatment of wounds 
and local lesions which might become the necessary infection-atrium. 
As tetanus follows more frequently injuries insignificant in themselves 
than large wounds or major operations, it behooves the surgeon to treat 
the minutest lesions with the greatest care and in strict accordance with 
antiseptic principles. Foreign bodies should be carefully searched for 
and removed. Even the most recent accidental wounds should be treated 
as infected wounds, and should be rendered aseptic by a thorough 
primary disinfection. The antiseptic treatment must be continued until 
the wound is completely healed, and during this time the injured part 
must be kept at rest. Wounds of the lower extremities must be treated 
by confining the patient to bed, and wounds of the upper extremities 
demand, in their treatment, fixation of the limb upon some kind of a 
splint or, at least, suspension in a sling. 

In acute cases of tetanus the most that can be expected from treat- 
ment is palliation. The excruciating pain is often only relieved by 
inhalation of chloroform. The administration of chloroform should be 
conducted by the physician in attendance or a reliable assistant, and 
should only be carried to the extent of relaxing the contracted muscles, 
and repeated as often as necessnry to procure rest. Morphia in doses 
of £ to \ grain, with ^ J<j grain of atropia, should be given hypodermati- 
cally every three or four hours until the desired effect is reached. In 
less severe cases the internal use of hydrate of chloral and potassic 
bromide, each in doses of from 15 to 20 grains, can be given every three 
or four hours with excellent effect. Woorara, which has been quite 
extensively used in the treatment of the disease, is absolutely contra- 
indicated, as its paralytic effect on the heart cannot fail in producing 
anything but a deleterious effect. 

Fancel and Frache report a case of tetanus successfully treated by 
hypodermatic injections of carbolic acid after the usual treatment by 
bromide of potassium and hydrate of chloral had failed to ameliorate the 
symptoms. The dose consisted of 1 centigramme every two hours, and 
the treatment was continued for seventeen days. The effect was almost 
immediate, the spasms becoming much less violent and less painful and 



TREATMENT. 433 

the patient's general condition showing marked improvement. The 
authors refer to the introduction of this mode of treatment by Baccelli, 
who reported a case in which he had employed it successfully in 1888. 
They do not, however, agree with him in attributing the efficacy of 
treatment to the sedative action of the carbolic acid on the spinal centres, 
but regard it as due to the parasiticide power of the remedy. 

The following remarks on the treatment of tetanus with antitoxin 
are taken from a valuable paper on this subject recently from the pen 
of R. T. Hewlett, published in The Practitioner : — 

" The method of preparing the tetanus antitoxin is similar to that 
employed in obtaining the diphtheria antitoxin. In practice it is met 
with in at least three forms : (1) the blood-serum, as such is sometimes 
used ; (2) the dry form, 1 gramme of the dry substance corresponding 
to 10 cubic centimetres of the fluid serum ; (3) the serum may be pre- 
cipitated with alcohol and the precipitate dried, — Tizzoni's antitoxin. 
This last is perhaps the most concentrated form. 

" Dose of the Antitoxin. — It is difficult to state definitely what should 
be the dose, for this has varied enormously in the published cases,, The 
smallest dose recorded is 5 or 6 cubic centimetres, the largest 167 cubic 
centimetres, which was given in one instance by Koux ; and it is remark- 
able that this enormous amount gave rise to no disturbance except urti- 
caria, which is also a frequent phenomenon with the diphtheria antitoxin. 
Of the fluid serum, which should have an immunizing power of at least 
1,000,000, I should be inclined to recommend 20 to 40 cubic centimetres 
for the first dose, followed by 10 to 20 cubic centimetres eveiy six or 
twelve hours afterward. Of the dried serum, 1 gramme corresponds to 
10 cubic centimetres of the fluid serum, and equivalent amounts are to 
be administered, — that is, 2 to 4 grammes for the first dose, followed by 
doses of 1 to 2 grammes ; while Tizzoni recommends 2.25 grammes of his 
antitoxin for the first dose and 0.6 gramme for subsequent doses. The 
amount and frequency of the injection of antitoxin are to based on the 
urgency and subsequent amelioration or otherwise of the symptoms, it 
being borne in mind that, the shorter the incubation period, the more 
acute will probably be the course of the disease. 

"Administration of the Dose. — The serum must be administered 
entirely by subcutaneous injections. The syringe should be a large one, 
with the capacity of at least 10 cubic centimetres, an ordinary-sized 
hypodermic syringe necessitating multiple punctures. Before using the 
syringe it should be taken to pieces and sterilized, and the skin to be 
punctured should be disinfected with l-to-20 carbolic lotion. If the 
fluid serum be employed the requisite amount should be poured out into 
a measure previously rinsed with boiling water to sterilize it, and the 

28 



434 PRINCIPLES OF SURGERY. 

vial quickly corked again and kept in a cool dark place, preferably on 
ice ; and if, after being opened once or twice, it becomes cloudy from 
the presence of bacteria, it must be discarded. The dried serum and 
Tizzoni's antitoxin must be finety powdered, and the dose weighed out 
and dissolved in 5 or 10 parts (according to convenience) of distilled 
water, which has been sterilized by boiling for ten minutes. As heat is 
fatal to the antitoxin, no warmth must be employed to hasten solution ; 
and syringes, vessels, etc., ought to be allowed to cool after sterilization 
before using. The antitoxin is injected subcutaneously into loose cellular 
tissue, as in the back between the scapulae or in the abdomen. 

" Employment of the Antitoxin (a) as a Remedy. — For the antitoxin 
to have a fair chance it ought to be administered as soon as the onset of 
tetanus is probable. Anj^ distinct sign, such as stiffness of the neck, 
difficulty in opening the mouth, or even considerable pain at the seat of 
injury or radiating from it, coming on a few da} r s after the accident 
without apparent cause, should at once lead us to employ this remedy. 

" The amount of antitoxin necessaiy for cure increases very rapidly 
with the duration of the disease v so that it is imperative to employ the 
remedy as soon as possible. 

" (b) As a Prophylactic. — The wonderful power exerted by the 
antitoxin in rendering the animal body proof against tetanus suggests 
whether it might not be wise in some instances to use it before the dis- 
ease declares itself. For example, a person sustains a lacerated wound 
which is freely soiled with the earth ; it is untreated and suppurates, and 
he comes under observation only when matters have gone from bad to 
worse. Here the onset of tetanus might not be unlikelj r later on, and a 
small injection of antitoxin, judging by the result of experiment, would 
render this impossible. The amount sufficient to immunize is much 
smaller than is required to cure, and probably an injection of 5 cubic 
centimetres of serum would be enough for this purpose." 

All patients suffering from tetanus should be kept in a quiet, dark 
room, and all kinds of excitement must be carefully avoided, as bodily 
and mental rest are important elements in the treatment. As mastica- 
tion is impossible, the patient must be nourished with liquid food, which 
he can sip through an elastic tube. If swallowing is impossible, a small 
elastic tube is introduced through one of the nostrils into the stomach, 
and food is administered at regular intervals by this method. In chronic 
tetanus warm baths are grateful to the patient and exercise a decided 
influence in ameliorating the symptoms. The surgical treatment of 
tetanus has yielded no better results than the internal use of drugs. In 
all cases the infection-atrium should be care full} 7 examined, and, if neces- 
sary, the wound or local lesion should be thorough!}* disinfected, as this 



TREATMENT. 435 

treatment may be the means of preventing further infection from this 
source. Scars should be excised and foreign bodies removed. 

Under the belief that tetanus is an ascending neuritis, nerve-section, 
or neurotomy, has been practiced for the purpose of preventing further 
extension of the inflammation by interrupting the continuity of the 
nerve; but the results, as could be expected, were disappointing, and the 
operation has fallen into well-deserved desuetude. When nerve-stretching 
was the rage in the treatment of all kinds of nerve-affections it was also 
applied in the treatment of tetanus, but the results were no better than 
after neurotomy. Nocht reported 24 cases of tetanus treated by this 
method, and of this number only 4 recovered, — the average percentage 
of recoveries in all cases of tetanus not treated by surgical resources. 
Amputation is only indicated in cases where the local conditions which 
give rise to tetanus make it necessary to resort to this operation without 
reference to the existence of tetanus. 



CHAPTER XVII. 

Hydrophobia. 

Hydrophobia, lyssa, canine madness, and rabies are synoi^mous 
terms used to designate a nervous disease caused by the bite of a rabid 
dog or other animal, attended with violent spasms if the patient attempt 
to swallow water or other liquids and by embarrassment of respiration 
from spasm of the laryngeal muscles. This disease never occurs spon- 
taneously in man, but is always the result of inoculation with the virus 
of a rabid animal. Although this* disease never originates elsewhere 
than in the dog and animals belonging to the same species, the wolf, 
fox, and jackal, the virus of rabies is capable of being communicated to 
all warm-blooded animals. It has been estimated that in man the disease 
is derived in nine out of ten cases from dogs ; sometimes it is contracted 
from cats, and sometimes, but very rarely, from foxes or wolves. The 
specific virus of hydrophobia appears to be generated in the glandular 
appendages of the mucous membrane of the mouth and throat, and is 
transmitted by the saliva of the rabid animal. For this reason it has 
been observed that inoculation is more apt to take place from a bite on 
an uncovered part of the body, as, for example, on the hands or face, 
than from a bite inflicted through the clothes, as in the latter case the 
greater portion of the saliva is deposited in the clothing. Not every 
person bitten by a rabid dog necessarily contracts the disease, as 
statistics have shown that about one-third of the animals and human 
beings bitten by mad dogs escape all danger. This partial immunity is 
explained in part by the virus being diluted, and being wiped from the 
teeth of the rabid animal by clothing ; and also by well-ascertained facts 
proving the absence of susceptibility to its action in certain individuals, 
both in animals and in man. 

Renault's careful experiments proved that one-fourth of the inocu- 
lated creatures escaped the effects of the inoculations, which were mortal 
in the other three-fourths. As in civilized countries the disease is con- 
tracted almost exclusively from rabid dogs, it is necessaiy to call atten- 
tion to the symptoms which characterize the disease in this animal, in 
order that it ma}^ be recognized in time, so that the infected animal can 
be isolated and kept in close confinement until the result shall prove or 
disprove the correctness of the diagnosis. It is a great mistake to kill 
(436) 



HYDROPHOBIA IN THE DOG. 437 

an animal suspected to be rabid, until by careful observation continued 
for some length of time, or from the result of the disease, a positive 
diagnosis can be made, and thus a great deal of unnecessary fear may 
be avoided. 

HYDROPHOBIA IN THE DOG. 

The name " hydrophobia," meaning literally a dread of fluids, is a 
proper designation for the disease as it occurs in man, because a peculiar 
dread of fluids is the most characteristic symptom of this disease in the 
human being. This symptom does not exist in the dog ; hence, in this 
animal we should speak of the disease as rabies, in man as hydrophobia. 
Fleming, who is an acknowledged authority on everything that pertains 
to hydrophobia, makes the following statement in reference to the ability 
of rabid animals to take fluids: " The many hundreds of rabid dogs seen 
by Blaine, Youatt, and others did not evince any marked aversion to 
fluids. On the contrary, the rabid animal is generally thirsty, and if 
water be offered will lap it up with avidity, and, at the commencement 
of the disease, will always swallow it. When, at a later period, the con- 
striction about the throat, which is symptomatic of the malady, renders 
swallowing difficult, the animal does not the less endeavor to drink, and 
lappings are as frequent and prolonged as deglutition is retarded. Even 
then we see the suffering creature, in despair, plunge its entire muzzle 
into the vessel, and gulp at the water as if determined to overcome the 
spasmodic closure of the throat by forcing down the fluid. Tantalus 
did not experience a greater torment with regard to water than does 
the- unlucky dog." The excessive sensibilit}' to pain and the action of 
the mildest external irritants so characteristic of hydrophobia in the 
human being are absent in the rabid dog. The animal is almost insen- 
sible to pain; he will dash himself against the bars of his kennel, tear 
them when his month is lacerated and bleeding, and he has been known 
to seize a red-hot poker in his mouth and hold on to it, apparently 
unconscious of suffering. Rabies in the dog must be suspected when 
the animal becomes dull, morose, mopes, and avoids his master and 
companions. During the commencement of the disease the animal is 
exceedingly restless, and is always on the move, prowling, snapping, and 
barking at imaginary objects. During the first two or three days there 
is rarely any tendency on the part of the animal to bite, nor to parox}^sms 
of uncontrollable fury. 

The danger in this stage to man and other animals comes from lick- 
ing rather than biting, for there is a propensity to extraordinary demon- 
strations of affection. After a time, however, a paroxysm of maniacal 
fury comes on, generally provoked by the sight of another dog. When 
this has subsided the animal again becomes controllable, but manifests 



438 PRINCIPLES OF SURGERY. 

a strange disposition to wander from place to place. He is now most 
dangerous. With a slinking and troubled aspect, his head and tail 
down, his eyes suffused, and foam at his mouth, he walks or trots along, 
snapping and biting at real and imaginary objects. He is only aggressive 
when attacked, and then his fury seems unbounded. When tired out 
from inadequate nourishment and the ceaseless wanderings, he drops 
exhausted in some out-of-the-way, solitary corner, and, after a rest, starts 
off again on his lonely journey, seemingly impelled by some irresistible 
force, and is finally killed or dies of exhaustion. The duration of the 
disease in the dog never exceeds ten days, and in the majority of cases 
the animal dies on the fourth or the sixth day after the appearance of 
the first s}^mptoms. From a study of the symptoms in this animal we 
can readily distinguish three stages: 1. Prodromal. 2. Irritation. 3. 
Paralytic. 

During the prodromal stage the most notable changes refer to the 
altered habits of the animal, while the stage of irritation culminates in 
attacks of ungovernable rage, provoked by real or fancied causes. The 
last, or paralytic, stage precedes death, which takes place from exhaustion. 
The period of incubation in the dog is variable ; it is usually from six 
to twelve weeks, but may extend to a much longer period. Frank, from 
a study of 200 observed cases of rabies in the dog, found that the aver- 
age period of incubation was three months; the extremes, six and seven 
days and eleven months. 

HYDROPHOBIA A MICROBIC DISEASE. 

The microbic cause of hydrophobia remains undiscovered at the 
present time. Bacteriologists have found and described different 
microbes in the tissues of hydrophobic animals, but the direct relation- 
ship between any of them and the causation of this disease has not been 
established. That the disease is of a microbic origin has been shown 
abundantly by its communicability and the artificial production of the 
disease in animals by inoculations with spinal-cord tissue from hydro- 
phobic animals. 

Raynaud and Lannelongue discovered that rabbits could be success- 
fully inoculated with saliva from rabid animals. Pasteur corroborated 
these observations by his own experiments, and cultivated from the 
blood of the infected rabbits in veal-bouillon a microorganism which in 
shape resembled the figure " 8 " ; this microbe was surrounded by an 
envelope of a gelatinous substance. In the cultures these rods are said 
to have become converted into chain cocci. Fowls and guinea-pigs were 
not found susceptible to inoculations with cultures of this microbe. 
After Pasteur had regarded these microorganisms as the cause of hydro- 



HYDROPHOBIA A MICROBIC DISEASE. 439 

phobia, he produced the same disease in rabbits by inoculations with 
saliva from healthy persons. Yulpian also succeeded in producing, by 
inoculations of normal saliva in rabbits, a disease which proved fatal in 
two days ; and with a small quantity of blood taken from the dead 
animals the disease could be communicated to other rabbits. The dis- 
ease thus produced was probably the same as that described by Stern- 
berg. This observer caused marked septicaemia in rabbits by injecting 
subcutaneously his own saliva in small doses. Injections of 1.25 to 1.75 
cubic centimetres, with few exceptions, caused death, usually within 
forty-eight hours. The constant and characteristic lesion found was a 
diffuse cellulitis, or inflammatory oedema, extending in all directions 
from the point of injection, attended with an abundant exudation of 
bloody serum, swarming with micrococci. Hemorrhagic extravasations 
in the connective tissue, and in the various organs, were of frequent 
occurrence, and changes in the liver and spleen, such as are common in 
rapidly-fatal septic diseases, were generally found. The disease could be 
communicated by dipping an hypodermic needle into the blood of a rabbit 
just dead from the result of an injection of saliva; inoculating a healthy 
rabbit, a rapidly-fatal septicaemia was produced. 

Gibier found, in the brain of hydrophobic animals, round, shining 
granules, which stained slowly and imperfectly in aniline dyes. 

Fol stained the brain-substance, according to Weigert's method, and 
discovered in the hollow spaces of the neuroglia groups of micrococci. 
The same microbe he found also in the nerve-fibres, between the sheath 
and axis-cylinder. Babes stained the specimens according to Gram's 
method, and found cocci in the cells, especially those of the surface of 
the brain. The cocci looked like diplococci, and were alwaj^s found 
aggregated in flat clusters. Fol and Babes claim to have succeeded in 
obtaining a culture of the microbes found in the brain. The former 
used for nutrient medium a filtrate of triturated brain and parenchyma 
of salivary gland. Of 8 dogs, rats, and rabbits inoculated with the first 
culture 5 died of well-marked hj^drophobia ; of 8 dogs inoculated with 
the second culture 4 died. The inoculations were always made by 
infecting the brain through an opening in the skull. The microbes in 
the cultures corresponded in shape and size with those found in the 
brain of hydrophobic animals. The third series of cultures produced 
only negative results. The microbes in these cultures were more readily 
stained than most of the first two cultures. Babes cultivated the 
microbe upon gelatin and coagulated blood-serum, to which was added 
brain-substance obtained from rabbits. The cultures grew slowly, and 
appeared as gray spots. Successful inoculations were made with the 
second and third generations. 



440 PRINCIPLES OF SCTRGERY. 

The microbe of hydrophobia exists, but so far it has not been discov- 
ered. That hydrophobia is a microbic disease can no longer be doubted. 
At the present time we can safely assert, without fear of contradiction, 
that the essential cause of this disease is a specific virus, which can only 
be reproduced within the living organism. As a small quantity of this 
virus introduced in the tissues can result in the most serious conse- 
quences, there exists no doubt that it possesses the properties pertaining 
to living organisms, more especially the capacity of reproduction after 
its entrance into the bod} r . That the disease is not caused by preformed 
toxins, communicated from the saliva of rabid animals, is shown by the 
variable and, on the whole, long stage of incubation which precedes all 
true infective processes. That hydrophobia is not caused by a soluble 
virus has also been shown by the experiments of Pencil. He triturated 
the brain of an hydrophobic animal and filtered it under a pressure equiv- 
alent to 3 atmospheres. The clear filtrate, when injected into animals 
susceptible to this disease, proved harmless ; while the residue on the 
filter, when used in a similar manner, invariably produced positive results. 
Another convincing proof of its microbic origin is the well-established 
fact that the disease can be artificially produced by implanting fragments 
of brain- or cord- tissue, taken from animals dead of rabies, into healthy 
animals. Furthermore, the blood and secretions of a rabid animal, its 
flesh and viscera, even the cooked flesh of a rabid ox, when eaten, would 
seem to be capable of conveying the disease. A pupil at the veterinary 
school of Copenhagen inoculated himself with the virus by cutting his 
finger slightly, while examining the body of a dog that had died of 
rabies on the evening before ; the student died of hydrophobia in six 
weeks. The clinical symptoms, as well as the pathological conditions 
found in the brain and spinal cord of hydrophobic patients, bear such a 
strong resemblance to tetanus that it appears probable that the microbe 
possesses analogous pathogenic properties, and that the actual develop- 
ment of the disease follows the action of its ptomaines upon the central 
nervous system. The latent stage of the disease, or the long duration 
of the period of incubation, depends either upon the slow growth of the 
microbes or that these reach the place slowly from where they exert 
their specific pathogenic properties. 

CAUSES. 

The microbe of hydrophobia does not penetrate the intact skin or 
healthy mucous membrane ; hence its entrance into the tissues takes 
place through an infection-atrium, — usually a punctured wound made by 
the bite of a rabid animal. As the microbe pre-exists in the saliva of 
the rabid animal, inoculation takes place at the time the wound is 



SYMPTOMS AND DIAGNOSIS. 441 

inflicted. Infection, however, can take place by the disposition of the 
infected saliva upon a surface from which absorption can take place. 
This can occur from the licking of a wound or abraded surface by an 
infected dog, as happened in one of my cases. In another case a lady 
of rank and fashion had a pimple on her face, from which she had 
scratched off the head. Hydrophobia was thus contracted, and she 
perished by this terrible disease. 

SYMPTOMS AND DIAGNOSIS. 

Great diversity of opinion exists as to the length of the period of 
incubation in man. In the 2 cases of hydrophobia that have come 
under my own observation the time of infection and the onset of the 
disease could be accurately fixed, and in both of them the stage of incu- 
bation lasted forty -two days. In 106 cases of Irydrophobia in human 
beings of all ages, collected by Bouley, 23 occurred within two months 
after infection, and the remainder came in at A r arying periods, the longest 
time noted being eight months. The cases reported where it was sup- 
posed the disease developed some }^ears after the persons were bitten 
by a dog lack accuracy of observation, and either the diagnosis was not 
correct or infection occurred more recently, as we have the authority of 
Fleming that the disease never occurs later than eight months after 
inoculation. Age appears to have some influence in modifjnng the dura- 
tion of the stage of incubation. In the cases where the length of this 
stage could be accurately ascertained, in patients under 20 years of age 
the mean period of incubation was six weeks ; from 20 up to 72 it was 
two months and a half. Before the actual development of the disease 
in man there is usually a period of a few days during which ill-defined 
premonitory symptoms can be detected. The wound through which the 
virus entered is the seat of a sensation of uneasiness and itching, and 
sometimes of actual pain, which radiates along the course of the nerves 
of a limb. The cicatrix often presents a congested appearance, and is 
tender on pressure. The patient is melancholic and irritable, and sleep 
is disturbed. The first characteristic symptom of hydrophobia in man 
is a sense of tightness and choking about the pharynx, attended by an 
hesitation in swallowing, especially of liquids. In one of my cases 
this early disturbance of the function of the muscles of deglutition 
made it possible for me to recognize the disease a few hours after the 
attack commenced. The patient was a sailor, about 30 years of age, 
who sent for me to treat him for a supposed cold. The only thing he 
complained of was a sense of constriction in the throat and difficulty 
in swallowing. In examining the cavity of the mouth and pharynx for 
evidences which would explain the existing s}nnptoms I found a profuse 



442 PRINCIPLES OF SURGERY. 

salivary secretion ; the mucous membrane of the pharynx was congested, 
but no signs of deep-seated inflammation could be found in the region 
of the tonsils. My suspicions were awakened at once. I ascertained 
tnat six weeks before a small pet dog owned by the family had died 
after a few days of illness, and that one day during this time, when the 
patient was lying on his back on the floor, the dog had licked a small 
sore on the anterior surface of the lobe of the left ear. Requesting the 
patient to drink water from a glass which I handed him, I noticed an 
hesitation on his part to comply with my wish ; but finally he grasped 
the glass with both hands, which trembled considerably, and, after 
waiting for the proper moment to come, applied it rapidly to his lips 
and made a desperate but futile effort to swallow; the attempt was 
repeated several times, but only a very small amount was swallowed. 
The next group of muscles to become affected with convulsive spasms 
are the muscles of respiration about the larynx. The symptoms of a 
well-developed case of hydrophobia are so well depicted by Fleming 
that I will give his own description : " The difficulty in swallowing rap- 
idly increases, and it is not long before the act becomes impossible, 
unless it is attempted with determination, though even then it excites 
the most painful spasms in the back of the throat, with other indescriba- 
ble sensations, all of which appall the patient and cause him to dread the 
very thought of liquids. Singular nervous paroxysms or tremblings 
become manifest, and sensations of stricture and oppression are felt 
about the throat and chest. The breathing is painful and embarrassed, 
and interrupted with frequent sighs or a peculiar kind of sobbing move- 
ment, or catching of the breath ; there is a sensation of impending suffo- 
cation and of necessity for fresh air. Indeed, the most marked symptoms 
consist in an horribly violent convulsion or spasm of the muscles of the 
larynx and pharynx, or gullet, by which swallowing is prevented, and at 
the same time the entrance of air into the windpipe is greatly retarded. 
Shuddering tremors, sometimes amounting to general convulsions, run 
through the whole frame, and a fearful expression of anxiety, terror, and 
despair is depicted on the countenance." 

Frothing at the mouth is rarely observed, but the viscid, tenacious 
mucus in the fauces and the profuse salivary secretion are frequently for- 
cibly ejected by hawking and spitting. Shortly before death the patient's 
mouth is often full of this mucus or froth, which in some cases is tinged 
with blood. The pulse at first is not much changed in force and fre- 
quency, but as the disease advances it becomes feeble and rapid, and often 
intermittent. The temperature is always increased. In both of my cases 
the thermometer registered from 101° to 103° F. at different times in 
the axilla. A post-mortem temperature of 106.2° F., taken in the rectum 
immediately after death, has been recorded. 



SYMPTOMS AND DIAGNOSIS. 443 

Occasionally the patient has hallucinations of sight and hearing, but 
usually the mental faculties are not much impaired. One patient, alluded 
to by Trousseau, heard the ringing of bells, and some mice run about on 
his bed. To the by-stander the most distressing phenomenon presented 
by hydrophobic patients is the fear of impending death, which is usually 
manifested soon after the attack, and remains throughout the whole 
course of the disease. No kinds of assurances or consolations are able 
to dispel it. Death occurs from complete exhaustion, in most cases 
attended by well-marked evidences of asphyxia from spasm of the 
glottis ; sometimes a convulsion is the final symptom, as in tetanus. 

The differential diagnosis between hydrophobia and tetanus is not 
always easy. In both diseases the stage of incubation is variable, and 
both are characterized by excessive excitability of the cerebro-spinal 
centre, as is evident from the muscular spasms and great hyperesthesia 
of the entire surface of the body during the stage of irritation. In 
hydrophobia infection always takes place from the bite of a rabid 
animal, and the difficulty in swallowing is caused by spasm of the phar- 
yngeal muscles, and not by tonic contraction of the muscles of mas- 
tication, notably the masseters, as is the case in tetanus. In tetanus 
respiration is impaired by rigidity of the respiratory muscles of the 
chest ; in hydrophobia by spasmodic contractions of the respiratory 
muscles of the larynx. Acute softening of the brain, and meningitis 
affecting the base of the brain and upper portion of the spinal cord, may 
give rise to symptoms that bear a faint resemblance to the clinical 
picture of hydrophobia, but a careful study of the symptoms, individu- 
ally and collectively, will disclose the real nature of the case under con- 
sideration. A purely neurotic affection has been described as lyssa 
nervosa falsa, which, it has been said, resembles genuine hydrophobia 
closely. Such cases are undoubtedly one of the manifold manifestations 
of hysteria ; and, if so, it can be differentiated from true li3 T drophobia 
by the absence of fever and by the fact that the muscular spasms are 
not limited to the muscles of deglutition and the muscles of the larynx. 
Trousseau speaks of lyssa nervosa falsa as a mental l^drophobia. 
Fayrer describes a case of this kind in a young Scotchman in India, and 
Bollinger quotes a case of a boy who was twice frightened into simulated 
hydrophobia. 

In making a positive final diagnosis of hydrophobia it is necessary 
to establish, in the first place, the fact that infection occurred from a 
rabid animal within eight months from the development of the disease ; 
and, in the second place, it is necessary to prove the existence of spasms 
of the muscles of deglutition in attempts to swallow liquids ; and if at 
the same time spasms of the muscles of the larynx interfere with the 



444 PRINCIPLES OF SURGERY. 

function of respiration, all doubt as to the nature of the difficulty has 
been removed. 

PROGNOSIS. 

If any doubt existed as to the nature of the case during life, an early 
fatal termination will corroborate the suspicions that may have been en- 
tertained. Decroix reports 9 cases of spontaneous recovery in dogs. 
In man this terrible disease is invariably fatal ; there is no authentic 
instance on record of recovery from genuine hydrophobia. Death results 
unexpectedly, suddenly, or from apoplex}^ asphyxia, or exhaustion, in 
from twelve hours to six days from the appearance of the first symptoms. 
The mean duration ofthe disease is about four da} T s. One of my patients 
died on the fourth and the other on the fifth day after the attack. In 
90 cases collected by Bouley, death occurred in 74 during the first four 
da}rs, the largest proportion of these being on the second and third days. 
In only 16 was life prolonged beyond the fourth day. 

PATHOLOGY AND MORBID ANATOMY. 

Hydrophobia, like tetanus, to which disease it is so closely allied in 
many respects, is characterized by the absence of gross pathological 
changes in the nervous centres and at the primary seat of infection. 
The scar which marks the wound or lesions through which infection 
occurred maj^ be red and slightly swollen, but these changes are not 
present in all cases. Hydrophobia is a disease in which there is every 
indication of irritation of certain nerve-centres and of a greatly in- 
creased reflex irritability. The centres irritated here are less those of 
the cerebral hemispheres than of the spinal cord and medulla oblongata. 
The symptoms point mainly to the medulla oblongata, and after death 
well-defined vascular lesions can be detected in this structure by means 
of the microscope. 

Similar lesions, but less marked, can be found in the spinal cord, and 
still to a lesser degree in the other parts of the nervous s}^stem. The 
most prominent condition is an accumulation of leucoc} 7 tes around the 
vessels in the substance of the cord 'and medulla oblongata (Fig. 142). 
Where the local lesion is most advanced the vessels are surrounded by 
several layers of leucocytes, which would indicate that the microbe of 
hydrophobia or its toxins produce an alteration of the capillary wall of 
sufficient intensity to entitle the process to be called inflammation. An 
increase of leucocytes is evident everywhere, so much so that the collec- 
tions which can be found in different parts have been called miliaiy 
abscesses. As the leucocytes show no evidences of even approaching 
transformation into pus-corpuscles, these aggregations of leucocytes do 



PATHOLOGY AND MORBID ANATOMY. 



445 



not deserve the name of abscesses. Klebs is of the opinion that the mi- 
crobe of hydrophobia does not enter the circulation directly, but invades 
in preference the lymphatic vessels, as he found general lymphatic en- 
gorgement in a recent case. The same author also discovered, particu- 
larly in the submaxillaiy gland, deposits of finely granular, strongly 
refractive corpuscles of a faint, brownish color, closely packed together 
in clusters and rows, which he regards as possibl\ T the vehicles for the 
transportation of the specific virus. Well-marked evidences of leuco- 
cytes have been found by many in the salivary glands. 




Fig. 142.— A Blood-vessel, from Medulla Oblongata in a Case of Hydrophobia. 
Large Numbers of Round Cells are Seen in its Sheath. X 350. (Coates.) 



There is l^perremia and oedema of the substance of the brain, 
medulla oblongata, and cord, and of their membranes ; deep-red injection 
of the mucous membrane of the pharynx and epiglottis, and sometimes 
recent swelling of the tonsils, follicular glands of the tongue, pharyngeal 
follicles, and of the lymphatic glands in the neighborhood of the jaw. 
The stomach and intestines show decided injection, and often haemor- 
rhagic extravasations. The lungs are charged with blood, with frequent 
points of capillary haemorrhage, and sometimes emphysema as a result 
of the d3'spno3a. In the kidneys, also, there are signs of irritation in 
the form of dilatation of vessels and haemorrhage. According to B61- 



446 



PRINCIPLES OF SURGERY. 



linger, the anatomical picture bears the strongest resemblance to that 
seen in cases of death from asphyxia or thirst. The conditions found, 
post-mortem, furnish an illustration that here an intense irritant is cir- 
culating in the blood, and the intensity of it may be judged from the 
fact that all these very marked appearances, although nearly all of 
them recognized only by the use of the microscope, occur in the short 
space of three or four days. 

TREATMENT. 

As hydrophobia is an absolutely fatal disease, the treatment resolves 
itself into prophylactic measures to prevent the disease, and means of 
palliation after it has developed. 




Fig. 143.— From the Salivary Gland in a Case of Hydrophobia. In the 
Middle is the Portion of a Duct ; abundant Round Cells abound 
it as well as the glandular structures shown in outline. x 350. 
(Coates.) 

Prophylactic Treatment. — The most effective prophylactic measures 
consist in preventing the spread of the disease, among animals, by the 
killing or strict isolation of animals which present symptoms of rabies. 
If animals which are suspected of being rabid are known to have 
bitten persons, they should not be killed at once, but should be kept in 
close confinement unknown to the injured person, until, by observation 
or the course of the disease, a positive diagnosis can be made. As soon 
as a positive diagnosis of rabies can be made, then the animal should be 
killed to prevent any further possibility of infecting other animals or 
persons. If a person is bitten b\' an animal which presents suspicious 
symptoms, no time should be lost to prevent infection by removing or 
destroying the virus. 

(a) Excision of Wound. — As the virus of hydrophobia appears to be 



TREATMENT. 447 

slowly diffused in the tissues, thorough local treatment of the wound 
may prove successful in preventing infection, even if resorted to several 
hours or days after inoculation has occurred. As soon as possible after 
the bite has been inflicted, a constrictor should be applied on the proxi- 
mal side of the wound and medical aid summoned without delay. In 
the meantime an attempt should be made to remove the virus from the 
wound by suction. In recent cases the simplest and safest treatment 
consists in excising the tissues in the immediate vicinity of the puncture, 
and after thorough disinfection close the wound with sutures. 

(b) Cauterization of Wound. — The same object is accomplished, but 
with a lesser degree of certainty, by cauterization. The most efficient 
caustic is the actual cautery. With the knife-point of a Paquelin cautery 
the wound is deeply cauterized, and the resulting eschar is protected 
against infection with pus-microbes by an antiseptic dressing. Of the 
chemical caustics the most valuable are caustic potassa, nitric acid, sul- 
phuric acid, and nitrate of silver, their efficiency being estimated in the 
order named. The authority for excision and thorough cauterization, as 
prophylactic measures, is to be found in the fact that, of 134 collected 
cases, in which bites of mad dogs were cauterized, 68 escaped and 42 
died, — a degree of immunity far above the average, which is 33 per cent. 
(Bouley). 

(c) Prophylactic Inoculations. — Pasteur has shown, by a long series of 
inoculations, made first in monkeys, rabbits, and guinea-pigs, and later 
exclusively in rabbits, that if the virus of hydrophobia is introduced 
into the brain of these animals the disease is invariably produced after 
a fixed period of incubation. As the period of incubation in successive 
inoculations in the same animal is shortened, we must take it for granted 
that the virulence of the material is increased. In the rabbit the first 
inoculation under the dura mater is followed by a period of incubation 
of fourteen days' duration, which, in successive inoculations in the same 
animal, is reduced to seven days. Back inoculations in dogs produce in 
these animals fatal rabies in the same length of time. Pasteur made an 
additional important discovery, as he found that the spinal cord of the 
inoculation rabbits, increased in virulence by successive inoculations, is 
again diminished in its virulence by preserving it in dry air, guarding at 
the same time against contamination with other microorganisms. This 
discovery led to a method by which the virulent action of such prepa- 
rations can be accurately graded, inasmuch as the action of the spinal 
cord, in the drying-room, in 7 to 8 days is reduced from its highest degree 
of virulence to nil. By using the spinal cord of rabbits treated in this 
manner in different strengths, at first weak and then gradually stronger 
preparations, it was found possible to render animals immune to the 
action of inoculation material of the highest potency. By this method 



448 



PRINCIPLES OF SURGERY. 



Pasteur succeeded in creating absolute immunity against the strongest 
hydrophobic virus in 50 dogs. The success of these prophylactic inocu- 
lations in animals enabled Pasteur to resort to the same method of 
treatment in persons bitten by rabid animals, as the long stage of incu- 
bation made it possible to carry out this treatment before the actual 
development of the disease was expected. The first human being sub- 
jected to this treatment was on July 5, 1885, and from that time until 
the close of the year 1889 2682 persons bitten by rabid animals, or 
animals that were suspected of being mad, with the result that of this 
large number onty 31 died, equivalent to 1.15 per cent., while the general 
mortality in persons under similar circumstances without such prophy- 
lactic inoculations has been at least 16 per cent. The danger is always 
greatest when the bite is inflicted b}' rabid wolves. Pasteur collected 
100 cases of persons bitten by rabid wolves, and of this number not less 
than 82 died. Pasteur had an opportunity to submit to his treatment 
38 persons bitten by rabid wolves, and of this number only 3 died, — a 
mortality of 7.89 per cent. 

The following tables represent Pasteur's work for four years : — 





Table A. 


Table B. 


Table 


C. 


Total. 








>s~? 






p^"~? 






>^ 






>^ 


Years. 


2d 

2^ 


d 


+3 +3 

S £3 

+3 O 


2d 


d 


+3 +3 

<3 © 
+3 o 


c 73 

2S 


d 


+3 +3 


BJrJ 


d 

© 


+3+3 




<3 P 


P 


o fc 


£ ® 


P 


O bi 


&£ 


P 


~ -i 


£ P 


P 


ofe 




PhH 




%3 


PhH 






PhH 




*5 


P^H 




^a 


1886. . . . 


231 


3 


1.30 


1926 


19 


0.99 


514 


3 


0.58 


2671 


25 


0.94 


1887. . . . 


357 


2 


0.56 


1156 


10 


0.86 


257 


1 


0.39 


1770 


13 


0.73 


1888. . . . 


402 


6 


1.49 


972 


2 


0.21 


248 


1 


0.40 


1622 


9 


0.55 


1889. . . . 


346 


2 


0.58 


1187 


2 


0.17 


297 


2 


0.67 


1830 


6 


0.33 


Total. . . 


1336 


13 


0.97 


5241 


33 


0.63 


1316 


7 


0.52 


7893 


53 


0.67 



The bites have been divided into three categories, — (1) those of the 
head and face ; (2) those of the hands ; (3) those of the limbs and 
trunk, — with the following result : — 





Tables A and B. 


Table C. 


Total. 




Persons 
Treated. 


d 

© 

P 


+3 +3 
IS 


o © 
Cj © 


d 
© 

P 


o b 


Persons 
Treated. 


d 
© 

5 


o b 




593 

376S 
2216 


14 

26 

6 

46 


2.36 
0.69 
0.27 


79 
619 
618 


1 
3 
3 


1.27 

0.48 
0.48 


672 

4387 
2834 


15 

29 

9 


2.23 
0.66 




0.32 


Total . . . 


6577 


0.70 


1316 


7 


0.53 


7893 


53 


67 







TREATMENT. 449 

Table A comprises those persons bitten by animals determined to 
be rabid by experiments in rabbits, made in the laboratory, or by the 
death of other animals or persons bitten by the same animal. 

Table B comprises those persons bitten by animals demonstrated to 
be rabid by the examination of a veterinary surgeon, or by the clinical 
signs shown during life. 

Table C comprises those persons bitten by animals suspected to be 
rabid. 

Gibier has treated 610 persons having been bitten by dogs or cats 
since the New York Pasteur Institute was opened until October 15, 1890. 
For 480 of these persons it was demonstrated that the animals which 
attacked them were not mad. Consequently the patients were sent back 
after having had their wounds attended, during the proper length of time, 
when it was necessary. In 130 cases the antihydrophobic treatment 
was applied, hydrophobia having been demonstrated by veterinary 
examination of the animals which inflicted the bites, or by the inocula- 
tions in the laboratory, and in. many cases by the death of some other 
persons bitten by the same animal. All these persons were fully pro- 
tected by the prophylactic inoculations. 

Protopopoff ( Gentralblatt fur Chirurgie, October 18, 1890), has made 
some experiments which tend to prove that Pasteur's prophylactic 
inoculations accomplish their object by the presence of a fixed virus, and 
not from the action of the microbe of hydrophobia. He took the spinal 
cords of animals which had died of rabies and removed from it the fixed 
virus by sterilization. He found that placing such cords in glycerin 
bouillon at a temperature of from 65° to 68° F. for from fifteen to 
twenty days accomplished this purpose, and that an emulsion prepared 
with spinal cords treated in this way can be used as a sterilized culture 
of the virus. A series of experiments and control experiments by the 
same author showed that immunity against experimental rabies could be 
secured by inoculating animals with the non-poisonous emulsion just 
described. Out of 19 dogs protected by inoculations with the sterilized 
virus, 14 were protected against the effects of Pasteur's virus, while 
every one of the 14 animals used for control experiments died. 

These results must convince the most skeptical of the practical 
utility of Pasteur's prophylactic treatment against hydrophobia, and, 
although the method will not be perfect until the microbe of this disease 
is discovered and mitigated (pure cultures are employed), this crude 
method must be viewed as a great boon to a class of patients otherwise 
exposed to the risks of contracting the most terrible and hopeless of all 
diseases. Pasteur institutes have sprung up in different parts of the 
civilized world, and the accumulated experience of all those engaged in 

29 



450 PRINCIPLES OF SURGERY. 

this kind of work bears strong testimony in favor of the prophylactic 
inoculations against hydrophobia as taught and practiced by Pasteur. 
At the bacteriological laboratory in Cuba 306 persons have been treated 
by the " double intensive " plan. Of these only 2 died after going 
through the full course, — a mortality of 1.63 per cent. All these cases 
were bitten by dogs proved experimentally and clinically to be rabid, or, 
at any rate, suspected. That the inoculations were conducted with due 
conservatism is indicated by the fact that only 306 persons were treated 
out of 700 applicants. Logario, of Chicago, has done excellent work in 
the prevention of hydrophobia by Pasteur's treatment. Some of the 
failures Pasteur attributes to the long intervals between the prophylactic 
inoculations, and in grave cases he now advises that successive inocula- 
tions should be made with cord-substance twelve, ten, and eight days 
old, during the first twenty-four hours; on the second day with material 
six, four, and two days old ; on the eighth da}' with material one day old, 
to be followed by two similar series of inoculations. By following this 
energetic plan of prophylactic treatment he has been able to secure pro- 
tection even in the most urgent cases ; that is, in cases where the stage 
of incubation had nearly terminated. 

Palliative Treatment. — The nature of the disease 'should, under no 
circumstances, be disclosed to the patient, as the people, high and low, 
educated and ignorant, are only too familiar with the terrible suffering 
caused by this affection, and its absolute certainty of a fatal termination 
in a few days. In one of my cases the patient had been made acquainted 
with the character of the ailment, and begged piteously that his life 
might be terminated by the administration of chloroform, knowing well 
that the intense suffering would continue to the last moment. As light, 
draughts of air, and noise of every kind increase the suffering by exag- 
gerating convulsive spasms, these aggravating causes should be elimi- 
nated from the patient's room, and only a limited number of persons 
should be admitted to render the necessarj' assistance and carry out the 
directions of the attending physicians. As the saliva of hydrophobic 
patients contains the specific virus, those placed in charge of the patient 
should protect themselves against inoculation by preventing the contact 
of the saliva with abraded surfaces, or, still better, by covering any 
abrasions which may exist with a collodium dressing. Thirst is quenched 
by administering water per rectum. Medicines by the mouth should not 
be given, as eveiy attempt at swallowing brings on violent spasms of the 
muscles of deglutition and the respiratory muscles of the larynx. Mor- 
phia combined with small doses of atropia should be given subcutaneously 
in such doses and at such intervals as will procure rest. The subcu- 
taneous administration of quinine and woorara has been advised, but 



TREATMENT. 451 

both of these remedies are more harmful than useful, and neither of them 
adds anything to the duration of life or alleviation of suffering. The only 
remedy which can be relied upon to afford prompt relief is chloroform 
by inhalation. Ether should never be used, as the hypersemic condition 
of the brain and spinal cord which is present in every case of hydropho- 
bia sufficiently contra-indicates its use. The inhalation of chloroform 
must be conducted by an assistant or a competent, reliable nurse, and 
should never be carried beyond the point where relief is afforded, and it 
should be repeated as often as the paroxysms return. 



CHAPTER XVIII. 

Surgical Tuberculosis. 

Tubercular lesions furnish a most excellent illustration, clinically 
and under the microscope, of the origin, course, termination, and tissue 
changes of what is known as chronic inflammation. An histological 
description of a tubercular nodule is a description of the pathology of 
chronic inflammation. Tuberculosis in all its forms is caused by a 
specific microbe the action of which upon the tissues produces his- 
tological and vascular changes which are characteristic of chronic 
inflammation. Of all the microbic diseases, with the exception of sup- 
puration, tuberculosis is of the greatest interest and importance to the 
surgeon. Of the greatest interest because the tubercular lesions which 
come under his care are more clearly understood from a bacteriological 
stand-point than most of the other surgical diseases, and of the greatest 
importance on account of their great frequency. That large class of 
ill-defined lesions which were grouped under that indefinite and vague 
term scrofula, in the text-books of but a few years ago, have been shown 
b} r recent research to be identical with the recognized forms of tuber- 
culosis, etiologically, clinically, and anatomically. In this chapter I 
shall aim to give a brief description, from a bacteriological and clinical 
stand-point, of such localized tubercular lesions which, by general 
consent, are regarded as surgical affections and requiring surgical 
procedures in their successful treatment. 

HISTORY OF THE MICROBIC ORIGIN OF TUBERCULOSIS. 

The first inoculation experiments with tubercular products were 
made b}^ Kortum in 1789 and Cruveilhier in 1826. In 1834 Erdt suc- 
ceeded in producing numerous nodules in the lungs of horses by inocu- 
lating them with tubercular pus, and Klencke, in 1843, produced 
tuberculosis in rabbits by intra-venous injections of tubercular matter. 
The results obtained from the crude inoculation experiments which 
were made 3^ears ago by Yillemin pointed strongly toward the infec- 
tiousness of tuberculosis. Yillemin 's experiments consisted in the 
subcutaneous insertion, behind the ear of rabbits, of fragments of 
tubercular tissue, or fluid taken from the cavit} r of a tubercular lung, 
recently removed from patients who had died of pulmonar}^ phthisis. 
The first animal thus infected was killed three and a half months after 
inoculation. The lungs and most of the internal organs were found 
diffusely infiltrated with miliary tubercle. His numerous later experi- 
ments 3'ielded similar results and led him to the following conclusions : 
" Phthisis of the lungs (like tubercular diseases in general) is a specific 

(452) 



HISTORY OF THE MICROBIC ORIGIN OF TUBERCULOSIS. 453 

infection. Its etiology depends on an inoculable agent. It can be 
readily communicated from man to animal by inoculation." 

Vogel repeated the experiments of Villemin on horses without 
success. Biffi, Verga, and Sangalli experimented on mules, cows, sheep, 
dogs, cats, mice, and chickens, with negative results. The experiments 
of Lanohans led him to the conclusion that tubercle could not be com- 
municated in the manner described by Villemin. He claimed that the 
inoculation material acted only the part of a foreign bod}', the inflam- 
mation following its insertion into the tissues differing in no way from 
the ordinary forms of inflammation. Among those who made successful 
inoculation experiments, and adopted the doctrines advanced by 
Villemin, may be mentioned Hevard and Cornil, Hoffmann, Cohn, Behier, 
Empis, Mantegazza, Bizzozero, Lebert and. Wyss, Klebs, Koester, 
Waldenburg, Bijuen, Simon, Sanderson, W. Fox, Papillon, Nicol, and 
Laveran. Hevard and Cornil were able to propagate tuberculosis by 
inoculations with crude tubercular material. They inoculated with 
genuine tubercular material, but failed with cheesy products. Marcet 
inoculated 11 guinea-pigs with the sputa of phthisical patients, and 
in 10 of them the experiment proved successful. Cohnheim injected 
tubercular material into the anterior chamber of the eye in rabbits, and 
succeeded in producing the disease artificially in this manner. Hueter 
produced tuberculosis of the iris by inserting into the anterior chamber 
of the eye in rabbits fragments of tubercular tissue. Toussaint showed 
that true tubercle, both in man and animals, reproduces itself indefinitely 
with absolutely constant and identical properties, and that it is quite 
capable of being transmitted from animal to animal without losing its 
virulence. 

Krishaber and Dieulafoy experimented on monkeys, and the results 
obtained led to the conclusions: 1. That human tubercle, when inocu- 
lated, kills a monkey in nine out of ten cases, with lesions analogous to 
those met in man. 2. The effect of the inoculation varies according 
to the substance employed ; the gray granulation is most, and the 
pulmonary parenchyma least, infectious. Schiiller and Lentz made 
successful inoculations with blood taken from tubercular rabbits. 
Lippl, Schweninger, Tappeiner, and Weichselbaum succeeded in pro- 
ducing the disease in animals by inhalation. Successful feeding experi- 
ments were made by Chaveau, Aufrecht, and Bollinger. Since Villemin 
announced the inoculability of tuberculosis diligent search was made 
to discover and isolate a specific microorganism which should be 
characteristic of this disease. 

The first cultivation experiments were made by Klebs in 1877. He 
found, by examining fresh specimens of tubercle of human beings, that 



454 PRINCIPLES OF SURGERY. 

they invariably contained bacteria. He cultivated them in egg-albumen 
and Bergmann's culture fluid, and found, by experiment, that the cultures 
produced the same effect in causing disease \)y inoculation as the tissues 
from which thej' were grown. Injections of the culture under the skin, 
into the muscles, lungs, pleural and peritoneal cavities, caused death of 
the animals from tuberculosis. Cultures made in a similar manner from 
scrofulous glands and lupous tissue produced the same effect in animals. 
Max Schiiller repeated the experiments of Klebs with the same results. 
He described the specific microbe as round and rod-shaped bacteria, the 
rods bulbous at both ends, composed of two, seldom more, spherical 
bodies. He found these microbes in great abundance in tubercular joints 
and tubercular foci in bone. He produced the disease artificially in 
animals which were previously inoculated by making contusions of 
joints. Other workers in the same field advanced theories, found and 
described microbes which were supposed to bear a direct etiological 
relationship to tuberculosis, but nothing definite was known on the 
subject until the father of modern bacteriology, Robert Koch, in 1882, 
announced to the profession his great discovery. He had found and 
demonstrated the true and essential cause of tuberculosis, the bacillus 
of tuberculosis, and, in his first publication, brought such convincing 
proof of the correctness of his claim that, with few exceptions, it 
brought conviction even to the minds of the most skeptical. He had 
not only found the bacillus, but showed that it was present in all tuber- 
cular lesions. He had isolated and cultivated the bacillus from tuber- 
cular tissue; and, finally, he had furnished the crucial test, — had produced 
tuberculosis, artificially, in animals by inoculation with pure cultures. 

A number of pathologists who inoculated animals with non-tuber- 
cular material claimed that they had produced pathological conditions 
analogous to those found in animals which had been infected with the 
virus of tuberculosis. Fragments of sponge implanted in the abdominal 
cavity produce a condition which resembles tubercular inflammation, and 
it has been asserted that powdered glass has a similar property. Schot- 
telius, Wargunin, Weichselbaum, and Martin have employed various 
substances by way of experiment, such as powdered cheese, brain- 
substance, lycopodium-seed, Ca3*enne pepper, and pulverized cantharides. 
The}' caused these to be inhaled in the form of a fine spray, with the 
result that they were almost invariabl} T able to produce, in different ani- 
mals, an eruption of nodules in the lung and sometimes in other organs. 
With Limburger cheese Weichselbaum produced an eruption in the lungs 
and kidneys of dogs, after fifteen inhalations during seventeen days, 
which, histologically, could not be distinguished from the products of 
genuine tuberculosis. Further experimentation soon showed that these 



HISTORY OF THE MICROBIC ORIGIN OF TUBERCULOSIS. 455 

were instances of pseudotuberculosis; that, while the gross appearances 
of the lesions resembled true tuberculosis, inoculations with this material 
never reproduced the disease, while inoculations with tubercular tissue 
could be done through a series of animals without impairing the potency 
of the virus or varying the constanc}' of the results. Koch's discovery 
did not lead to such energetic search for the bacillus of tuberculosis 
among surgeons as physicians, because, as Konig asserts, the symptoms 
and signs of the tubercular affections coming under the observation of 
surgeons are so characteristic that, for practical purposes, a correct diag- 
nosis could be made in the majority of cases without a knowledge of 
their microbic nature and the improved methods for making a positive 
diagnosis derived therefrom. Koch himself, in the publication above 
referred to, demonstrated the presence of the bacillus in lupus, the so- 
called scrofulous glands, tubercular joints, etc. He called attention to 
the fact that in these affections the bacillus can be constantly found in 
giant cells and between the epithelioid cells, while it is more difficult to 
find it in cheesy products unless caseation has taken place quite rapidly. 

Koch examined 19 cases of miliary tuberculosis, in which bacilli 
were found in every nodule ; 29 cases of phthisis, in every one of which 
bacilli were found most numerous, with the exception of the sputum, in 
recent caseous foci and in the walls of cavities undergoing speedy de- 
struction. He also, found them constantly in tubercular ulcers of the 
tongue, tubercular pyelonephritis, and tuberculosis of the uterus and 
testicles; also in 21 cases of tuberculosis of lymphatic glands. Further, 
in 13 cases of tuberculosis of joints and in 10 cases of tuberculosis of 
bone; in 4 cases of lupus, in which only a single bacillus could be seen 
in the giant cells; in 1*7 cases of Perlsncht in cattle. Finally, in animals 
inoculated with tubercular virus : 273 guinea-pigs, 105 rabbits, 44 field- 
mice, 28 white mice, 19 rats, 13 cats, besides dogs, chickens, pigeons, 
etc. Examinations of sputa and organs in various other non-tubercular 
affections for bacilli resulted, without exception, negatively. 

Weichselbaum, Meisels, and Lustig found tubercle bacilli in the 
blood in cases of acute miliary tuberculosis, both during life and after 
death. Schuchardt and Krause examined 40 cnses of tuberculosis of 
bones, joints, tendon-sheaths, and the skin in Volkmann's clinic, and 
never failed in finding bacilli, although in some specimens careful and 
prolonged search had to be made. 

Schlegtendal examined 520 specimens of pus from tubercular sup- 
purations, and found bacilli present in about 75 per cent, of the cases. 
Mogling found the bacillus never absent in tubercular pus from 53 
patients. The literature on the etiological relation existing between the 
bacillus of tuberculosis and the affections of the skin, glands, bones, and 



456 PRINCIPLES OF SURGERY. 

joints, which have heretofore been grouped under the head of scrofula, 
is immense ; but the foregoing quotations will suffice to show the regu- 
larity with which the bacillus can be found in the tissues of the so-called 
scrofulous affections, as well as in all recognized clinical forms of 
tuberculosis. 

DESCRIPTION OF BACILLUS TUBERCULOSIS. 

The tubercle bacillus, with the exception of the bacillus of septi- 
caemia in mice, is the smallest of the known bacilli. The length of each 
rod varies from one-fourth to three-fourths of the diameter of a red 
blood-corpuscle. The thickness corresponds to that of the bacillus of 
sepsis in mice. The rods are either straight or, what is more common, 
bent or curved near the centre. 

In cultures and in the tissues they occur singty, in pairs, or in bun- 
dles. In a state of fructification the bacilli contain from two to six 
spores. In stained rods the spores appear as clear, minute, ovate spaces, 
as they are not affected by the coloring material. In some bacilli the 
spores form slight projections on the sides of the rod. Reproduction 
by spore formation also takes place in the tissues within the animal body. 
In badly-stained specimens, and on superficial examination, the spores 
impart to the bacillus the appearance of a chain coccus; but, examined 
closely, it is seen that the protoplasm of the bacillus is continuous, and 
the apparent interruptions are due to the presence of the spores. The 
bacilli of tuberculosis are non-motile, and consequently possesses no 
power of locomotion, and cannot penetrate into the tissues without 
assistance. In the tissues they are found in the interior of giant cells 
and within and between epithelioid cells. They are constantly found in 
places where the tubercular process is commencing or actively progress- 
ing. In the beginning the}' are isolated and in the interior of cells; 
later, they become more abundant and form groups. In cheesy deposits 
they are either entirely absent or few in number. The virulence of 
caseous material is due mostly to the presence of spoi*es, which may re- 
main in a latent condition and yet retain their power of reproduction 
under more favorable conditions for an indefinite period of time. As 
soon as giant cells appear, they contain bacilli in their interior, as a rule. 
In some giant cells only one bacillus can be found, and then it occupies 
a part of the cell which contains no nuclei. 

In giant cells with numerous bacilli the latter arrange themselves 
around the periphery in the interior of the cell, while the centre contains 
few or none. 

The first ingress of bacilli into the diseased tissues probabty takes 
place by wandering cells, which transport the non-motile microbe. In 



PLATE I. 



/ 



Tubercle Bacilli Containing Spores. Zeiss -^ 0.4. (R. Koch.) 



• « -• JHKk •* V 'V ♦ fll ^V 

» » • • JBtH* X X ♦ • ^^ 



.»» 







Tubercle Bacillt from a Tubercular Cavity. Carbol-Fuchsin, Nitric 
Acid, Methyl-Blue. Zeiss Jg 0.4. 



DESCRIPTION OF BACILLUS TUBERCULOSIS. 



457 



many inoculation experiments such bacilli-containing cells have been 
found in the blood and tissues. 

Staining.— The peculiar behavior of the bacillus of tuberculosis to 
different staining material enabled Koch not only to discover this 




Fig 141 —Giant Cell with One Tubercle Bacillus. Section from 
Lupus of Skin. 700:1. {Fluegge.) 

microbe, but also to differentiate it from all other microbes. While the 
aniline dyes and other nuclear staining material showed no microorgan- 
isms in tubercular products, the bacillus came plainly into view if a small 




Fig. 145 —Giant Cell. Miliary Tuberculosis. 700:1. {Fluegge.) 

quantity of alkali were added to the aniline solution. Later experience 
proved that the same effect is produced if, instead of an alkali, aniline, 
toluidin, turpentine, carbolic acid, or ammonia is added. All of these 
substances aid the penetration of the staining fluid into the bacillus. 



458 PRINCIPLES OF SURGERY. 

Of especial advantage is the discovery, also made by Koch, that the 
staining fluid is fixed more permanently by treating with nitric or muri- 
atic acid the sections stained with alkaline aniline dyes, — a procedure 
which removes the staining from the cells, nuclei, and all other bacteria, 
while the tubercle bacillus alone remains stained. The preparation is 
further completed by staining once with one of the ordinary aniline dyes, 
which stains the cells and nuclei and other bacteria, so that the tubercle 
bacillus, for instance, appears red, the nuclei and other bacteria blue. 

Most of the bacilli (Plate II) contain spores, the majority of them 
slightly curved or bent ; they lie free,— that is, outside the cells. Where 
they appear to be within the cells, a close examination shows them to be 
either upon or underneath the cells. 

For section-staining Ehrlich's method is the best : — 

Saturated alcoholic solution of methyl-violet or fuchsin, . . 11 parts. 

Aniliue water, 100 " 

Absolute alcohol, 10 " 

Sections are left for twelve hours in this solution. Treat the speci- 
mens with l-to-3 solution of nitric acid a few seconds ; wash in alcohol 
(60 per cent.) for a few minutes; after-stain with diluted solution of 
vesuvin or methylene-blue for a few minutes ; wash again in 60-per-cent. 
alcohol; dehydrate in absolute alcohol; clear with cedar-oil; mount in 
Canada balsam. 

Ziehl-Neelson Method. — Leave the sections for fifteen minutes in 
carbol-fuchsin solution; decolorize in 25-per-cent. solution sulphuric or 
nitric acid ; wash in 6 per-cent. alcohol ; immerse in a saturated aqueous 
solution of methylene-blue for double stain ; wash, dehydrate, and mount 
in balsam. The examination of fluids for bacilli can be done rapidly and 
most satisfactorily by Gibbes' method : — 

GIBBES' MAGENTA SOLUTION. 

Magenta, 2 parts. 

Aniliue oil, 3 " 

Alcohol (specific gravity 0.830), 20 " 

Distilled water, 20 <-' 

Stain cover-glass preparations In this solution for fifteen or twenty 
minutes ; wash in l-to-3 solution of nitric acid until the color is removed ; 
rinse in distilled water; after-stain with methylene-blue, methyl-green, 
iodine-green, or a watery solution of c^soidin, five minutes ; wash in 
distilled water until no more color comes away ; transfer to absolute 
alcohol for five minutes ; dry, and preserve in Canada balsam. 

Cultivation. — The best culture medium for the bacillus of tubercu- 
losis is solid, sterilized blood-serum of the cow or sheep, with or without 
the addition of gelatin, at a temperature of 3T° to 38° C. (98.6° to 
100.4° F.). The bacillus grows very slowly, and only between the tern- 



PLATE II. 



w 



I, 



\ 



Y 



■ -■ 

Up y >t? 



y 



\ 



^NJ 




^N / 



\ 



\ 



M 



- 



'rt 



>■■ 






\ 



X 



\ / 



N 



Glass-Slide Preparation from the Tissue Juice of a Fresh Inocu- 
lation Tubercle. Ehrlich's Staining. Zeiss, homog. immers., yV 0.4, magnified 
about 1500 times. (Baumgarten.) 



<S 



m 



* 







From Encysted Bronchial Glands in Miliary Tuberculosis. Giant Cell 
with Radiating Arrangement of Bacilli. 700 diam. (Koch.) 



PLATE III 




Tubercle Bacilli. Colony on Solidified Blood-serum, 
Fourteen Days Old; Stained with Carbol-Fuchsin, Decolorized with 
Dilute Nitric Acid. X 100- (Frankel and Pfeiffer.) 



BurkaM c FBtridbeCoLLth?hiia 



INOCULATION EXPERIMENTS. 



459 



peratures of 30° and 41° C. (86° and 105.8° F.). In about a week or 
ten days the culture appears as little whitish or yellowish scales and 
grains. Cultivations can also be made in a glass capsule or solid blood- 
serum, and the appearance of the growth studied under the microscope. 
The scales or pellicles are then seen to be made up of colonies of a per- 
fectly characteristic appearance. The growth 
ceases after three or four weeks. The blood- 
serum is not liquefied unless putrefactive bac- 
teria contaminate the culture. Frankel figures, 
in his u Atlas der Barter ienkunde" a luxuriant 
culture of the bacillus of tuberculosis upon 
glyeerin-agar. 

Nocard and Roux have found that coagu- 
lated blood-serum is improved for the growth of 
the bacillus by adding peptone, soda, and sugar. 
A further addition of 6 to 8 per cent, of glycerin 
favors the growth of the bacillus still more, 
while, at the same time, it prevents the formation 
of a dry crust upon the culture medium, which 
otherwise forms by evaporation. They also made 
successful cultivations upon agar-agar bouillon, 
to which was added 6 to 8 per cent, of glycerin, 
kept at a temperature of 39° C. (102.2° P.). 

Koch has cultures 3 years old which have 
passed through 40 generations and still retain 
their virulence, showing plainly the longevity 
and tenacity of the bacillus of tuberculosis. 

INOCULATION EXPERIMENTS. 

Long before the discovery of the bacillus of 
tuberculosis by Koch genuine tuberculosis was 
produced artificially in animals by inoculation 
with the products of tubercular inflammation. 
Hueter inoculated the anterior chamber of the 
eye in rabbits with lupous tissue, and produced 
typical tuberculosis of the iris. Schiiller introduced fragments of lupous 
tissue directly into the veins of animals, and in this wa} r caused pulmo- 
nary tuberculosis. Koch produced tuberculosis in animals susceptible 
to this disease b}^ implantation of tubercular tissue in various localities 
and by inoculation with pure cultures, the experiments yielding, almost 
without exception, positive results. The same author inoculated the 
anterior chamber of the eyes in 18 rabbits from 5 cases of lupus, and in 



M 



Urn 



\M 



fjjd 



Fig. 146.— Vegetations of 
Tubercle Bacilli upon 
Sterilized Blood-Serum, 
Twenty-Six Weeks Old. 
Natural Size. {Baum- 
garten.) 



460 PRINCIPLES OF SURGERY. 

all of them tuberculosis of the iris was produced, and, if life were pro- 
longed for a sufficient length of time, was followed by tuberculosis of 
the lymphatic glands of the neck, lungs, kidneys, liver, and spleen. 
Similar results were also obtained in 5 guinea-pigs. Cornet has made 
numerous experiments, in Koch's laboratory, on animals, to ascertain 
the inoculability of tuberculosis through abrasions of the skin, or a pure 
culture of tubercle bacilli was applied to a cutaneous abrasion ; the result 
in most, if not all, cases is a local tuberculosis in the adjacent lymphatic 
glands, and, later, a general miliary tuberculosis. 

The same author made, more recently, a long series of experiments 
on dogs, to ascertain the different avenues through which tubercular in- 
fection is known to take place. Tubercular sputum and pure cultures 
inserted into the lower conjunctival sac in healthy dogs produced tissue 
hyperplasia at the seat of inoculation, and was followed by infection of 
the cervical glands on the corresponding side. Some of the glands 
underwent caseation, and the presence of bacilli could be demonstrated 
in all of the pathological products. In other animals the tubercular 
material was introduced into the nasal cavity. The cervical glands, 
especially those on the corresponding side, became enlarged and caseated. 
Infection through the mouth, by depositing the tubercular material in a 
depression made with a blunt instrument between the canine teeth, re- 
sulted also in tuberculosis of the glands of the neck. Infection of the 
external meatus of the ear, without creating an infection-atrium intention- 
ally, was followed by infection of the lymphatic glands behind the ear 
and along the neck on the same side. Cutaneous tuberculosis in the 
form of an ulcerating lupus was produced by shaving the skin on one 
side of the nose and face, and scratching it with a finger-nail infected 
with a pure culture. Injection of pure cultures into the healthy vagina 
of bitches resulted in local tuberculosis and secondary infection of the 
inguinal glands. Inoculations of other parts were followed by the same 
train of symptoms, — local tuberculosis at the seat of infection, followed 
by dissemination of the process along the course of lymphatic channels. 
The lungs were found affected only in two of the animals. These ex- 
periments show conclusively that the bacillus of tuberculosis, introduced 
through superficial peripheral infection-atria, seeks the lymphatic chan- 
nels, through which it is extensively disseminated before general infec- 
tion takes place. Cornil and Leloir implanted lupus-tissue into the 
peritoneal cavity of guinea-pigs, and in 5 cases out of 14 experi- 
ments produced peritoneal and general tuberculosis. Pagenstecher 
and Pfeiffer took the secretion of the conjunctiva from patients suffering 
from lupus of this structure, and injected it into the anterior chamber of 
the eye in rabbits. After five to six weeks nodules could be seen on the 



INOCULATION EXPERIMENTS. 461 

surface of the iris, which, on examination, were found to be in every 
respect identical with tuberculosis of this organ. Doutrelepont inocu- 
lated the peritoneal cavity in 50 guinea-pigs, and in 8 rabbits the anterior 
chamber of the eye with the same material, with the result that in all of 
the animals local tuberculosis was produced at the point of inoculation, 
and in 3 of the guinea-pigs and in 1 rabbit the local disease was followed 
by general tuberculosis. 

Inoculations with material from so-called scrofulous glands produce 
the same effect as when lupus-tissue is used, and we are, therefore, forced 
to conclude that these glands owe their existence to the same cause. 
Arloing prepared an emulsion from a scrofulous (tubercular) gland, 
caseous in its centre, which was taken from a boy aged 14. This was 
injected beneath the skin of 10 rabbits, and the same number of guinea- 
pigs. Visceral tuberculosis developed in all of the guinea-pigs, but the 
rabbits remained health}', except that 2 showed yellow, caseous granula- 
tions at the seat of inoculation. Some glands excised from the neck of 
a young woman produced tuberculosis both in rabbits and guinea-pigs. 
The patient died three weeks after the operation from miliary tubercu- 
losis. From these experiments he inferred that scrofula and tuberculosis 
were nearly allied affections, but caused b}^ different agents, or they were 
derived from the same virus, of which the activity was modified in the 
scrofulous form. 

That the number of bacilli injected has a great deal to do with 
the result has been satisfactorily demonstrated by Bollinger. He found 
that infectious milk from a tubercular cow, which produced local 
tuberculosis by intra-peritoneal injections, lost its virulence if diluted 
from 1:40 to 1:100. The sputum of phthisical patients was found much 
more virulent, and had not lost its power to produce tuberculosis on 
being diluted 1:100,000, on being injected into the abdominal cavity, or 
the subcutaneous connective tissue. Feeding experiments with sputum 
diluted 1:8 3 7 ielded negative results. Pure cultures remained virulent 
when diluted 1:400,000. All the experiments proved that the more con- 
centrated the material and the greater the number of bacilli, the more 
rapid and intense was the development of the lesion caused by the injec- 
tion. It was estimated that about 820 bacilli were necessary to produce 
tuberculosis in guinea-pigs. Intra-peritoneal injections did not always 
produce peritoneal tuberculosis, and in cases where this did not occur 
the organs affected were the lymphatic glands, spleen, lungs, liver, kid- 
neys, and genital organs, in the order of frequency named, showing con- 
clusively that localization does not invariably take place at the point of 
primary infection. 

Direct intra- venous infection b}^ injections of pure cultures, sus- 



462 PRINCIPLES OF SURGERY. 

pended in distilled water, is the most effective way in which diffuse 
miliary tuberculosis can be artificially produced in animals with unfail- 
ing certainty. Koch succeeded also in producing the disease in rabbits, 
guinea-pigs, rats, and white mice, by inhalation. A pure culture, sus- 
pended in distilled water, was used with a hand-spray, and the cages in 
which the animals were kept were filled with the infected spray. The 
animals were killed after twenty-eight days, and all of them showed 
unmistakable signs of pulmonary tuberculosis. 

INOCULATION-TUBERCULOSIS IN MAN. 

The opinion that tubercle is capable of inoculation was held by 
ancient writers, and Laennec, himself, after a nick from a saw while 
making a necropsy on a phthisical subject, thought that he witnessed an 
example of inoculation in a small tubercle that developed in the injured 
skin, but twenty years afterward this distinguished clinician was in good 
health, though finally he died of phthisis. 

Schmidt made a number of experiments to ascertain the effect of 
inoculations of superficial abrasions of the skin with the virus of tuber- 
culosis. In guinea-pigs he made abrasions in the skin, to which he 
applied tubercular material and covered the point of inoculation with 
collodium. All of his experiments failed in producing tuberculosis, 
while in the control animals, in which the infectious material was intro- 
duced into the subcutaneous tissue, or into the peritoneal cavity, tuber- 
culosis developed without a single exception. He believes that the 
results of these experiments are onry corroborative of the assertion 
previously made by Bollinger and Koch, that the susceptibility of the 
cutis for tubercular infection is slight. A sufficient number of authen- 
ticated cases, however, have been reported during the last few years, to 
prove that in man tuberculosis is not infrequently contracted by the 
absorption of tubercular material through small wounds and superficial 
abrasions of the skin. Volkmann, a number of years ago, made the state- 
ment that tubercular infection never takes place through a large opera- 
tion wound, or at the site of severe injuries, but that localization of the 
bacillus is likely to take place in parts the seat of very slight contusions, 
or what may appear at the time as an insignificant injury. He exphuned 
this by assuming that the active tissue changes which take place during 
the process of regeneration after a severe trauma prevent the infection. 

In studying the cases of inoculation-tuberculosis, which will be 
referred to below, it will be seen that the infection-atriurn was always 
caused by a trivial injur} 7 . A very interesting case of inoculation 
tuberculosis came under my own observation a few years ago. The 
patient was a strong, health} 7 young woman, with a good family history, 



INOCULATION-TUBERCULOSIS IN MAN. 463 

who was employed in a rag establishment in sorting rags. Two months 
before she came under my care she noticed a small sore on the dorsal 
side of the right index finger, near the metacarpo-phalangeal joint. The 
place ulcerated, and the granulation tissue which appeared melted rapidly 
away, forming a deep excavation, which had the extensor tendon for its 
floor. Two weeks later a nodule appeared in the course of the lymphatic 
vessels, near the elbow-joint, over the anterior aspect of the arm, which 
was soon followed by the formation of three other nodules between this 
point and the primary seat of infection. General health not impaired in 
the least. Inflamed foci neither painful nor tender on pressure ; presented 
distinct evidences of fluctuation. All the foci were excised and presented 
the characteristic appearances of tubercular tissue. The primary focus, 
after excision, left such a large defect that it was found impossible to 
close the wound by suturing, and consequently the surface was covered 
with Thiersch's grafts taken from the arm. Primary union of all the 
sutured wounds and speedy, definitive healing of the defect at the primary 
seat of infection. 

There can be no doubt whatever that in this case infection occurred 
through a small wound of the index finger, by handling contaminated 
rags, which was followed b}^ dissemination of the bacilli through the 
tymphatic vessels in direct communication with the primary infection- 
atrium. I have had also under treatment a well-marked case of exten- 
sive subcutaneous tuberculosis of the hand, in the person of the mother 
of several children who had died of pulmonary tuberculosis. The 
disease originated near the tip of the index finger, at the site of a former 
abrasion, in which a papillomatous swelling formed. This ulcerated and 
healed partly, when the disease commenced to spread along the subcu- 
taneous connective tissue, and when the patient came under m}^ observa- 
tion it had extended almost over the entire dorsum of the hand. A 
number of fistulous openings existed, which discharged daily only a few 
drops of thin, serous pus. The subcutaneous tissue was transformed 
into a mass of granulation tissue, which was removed with a small spoon 
through multiple incisions, and the wound surfaces were freety iodo- 
formized. The process of repair was slow, but satisfactory. Martin du 
Magny has collected the clinical material of cases of inoculation-tuber- 
culosis, and in his comments upon the cases asserts that the sputum of 
phthisical patients and animal excretions were the usual carriers of the 
bacilli ; consequently the affection is most frequently met with among 
physicians, nurses, butchers, and teamsters. The external appearances, 
manifested at the point of inoculation, consist in the formation of a red 
nodule in the skin, which increases slowly in size and forms miliary 
abscesses, in which papillomatous proliferation takes place, and around 



464 PRINCIPLES OF SURGERY. 

which a new zone of infiltration forms, which in turn again suppurates 
and becomes papillomatous. The centre heals with the formation of a 
flat cicatrix, while the destructive process progresses slowly in a 
peripheral direction. 

Hanot has collected 6 cases, 1 of which came under his own observa- 
tion. In this case the patient was in the third stage of phthisis, and 
died soon after from a tubercular ulcer on the arm of at least two years' 
standing, while the history of cough only dated from the last two 
months, which would show that the cutaneous lesion preceded the pul- 
monary, and was the cause of the phthisis. In the cases which he 
collected the sources of inoculation were necropsies on tubercular 
patients, handling old bones, pricking the hand with a fragment of 
porcelain from the broken spittoon used by a phthisical patient, and 
in 4 of the cases the tubercular character of the cutaneous lesion was 
verified by finding the bacilli. 

Eiselsberg has observed 4 cases of inoculation-tuberculosis dur- 
ing the last few 3 r ears. The first case was a girl 16 }^ears old, in whom 
the disease developed in the track of a perforation of the lobe of the ear 
made preparatoiy to the wearing of an ear-ring, and which was kept from 
closing by the insertion of a thread. The tubercular product appeared 
in the shape of a hard swelling the size of a hazel-nut. The second case 
was a j'oung man who injured himself with the point of a knife above the 
external epicondyle of the humerus. Eighteen days later a swelling, the 
size of a pea, appeared at the site of injury, with an ulcerated surface 
covered b}> r pale, flabby granulations. In the axilla of the same side one 
of the lymphatic glands was found enlarged to the size of a hazel-nut. 
The third case concerned a woman 50 years of age, who was supposed 
to have infected herself b}^ washing the clothes of a person the subject of 
a tubercular abscess of the spine, and who with her fingers scratched an 
acne pustule on her face. At this point, six to eight days later, a pain- 
ful swelling, the size of a pea, formed, which subsequently became indu- 
rated, and opened spontaneously in six weeks. At the end of three 
months the place of inoculation presented an ulcer with indurated mar- 
gins. In the fourth case the inoculation followed in the track made b}^ 
the needle of a hypodermic syringe, in a girl 20 years of age. The 
swelling which appeared opened after six weeks, and a small quantity of 
pus was discharged. Four months subsequent^ the fistulous opening 
communicated with an abscess-cavit3 T , the size of a silver dollar, lined by 
a wall of granulation tissue. In all of these cases no evidence of tuber- 
culosis could be detected in anjr of the internal organs, and the local dis- 
ease could be traced in every instance to some antecedent lesion, through 
which the infection had evidently taken place. The diagnosis in all cases 



INOCULATION-TUBERCULOSIS IN MAN. 465 

was based on an examination of the granulation tissue for the bacillus 
of tuberculosis, which was always found present. 

Another case of tubercular infection through ear-rings is related 
from Vienna in a girl, 14 years of age, of a perfectly healthy family, who 
wore ear-rings left to her by a friend who had died of pulmonary tuber- 
culosis. Soon ulcers appeared on the lobes of both ears, the cervical 
glands became swollen, and percussion and auscultation revealed infil- 
tration of the apex of the left lung. Tubercle bacilli were found in the 
ulcers and sputa. This case is only another instance of inoculation- 
tuberculosis, where, from the point of infection, the disease extended 
along the lymphatic system, and, finally, S3^stemic infection from the 
entrance of bacilli into the general circulation. 

In the cases of inoculation-tuberculosis cited above, infection 
occurred through some slight lesion, puncture, or abrasion, which fur- 
nished the necessary infection-atrium for the entrance of the bacillus 
into the tissues, but a number of cases have been reported by reliable 
observers where infection took place through a larger wound or granula- 
tion surface. Middeldorpf reports the case of a healthy carpenter, who 
opened his knee-joint by the cut of an ax, and dressed the wound with a 
soiled handkerchief. The wound healed kindly, but later the joint be- 
came swollen, tender, and painful. Resection was performed, and on 
examining the capsule it was found very much thickened. In the gran- 
ulation tissue tubercle bacilli were found. Wahl amputated the arm of 
a boy suffering from gangrene, the result of an injury, and discharged 
the patient with the wound completely healed, except a small granula- 
tion surface from which the drainage-tube had been removed. At first 
the wound was dressed by a girl suffering from tuberculosis. The wound 
soon showed all the characteristic appearances of fungous disease, and 
the lymphatic glands became infected from this source. I have seen in 
numerous instances large wounds made for the removal of tubercular 
glands become infected a week or two after the operation, after the 
superficial wound had apparently healed. In such cases the overlying 
cicatrix is subsequently completely destroyed by the granulations under- 
neath. The energetic use of the sharp spoon and free iodoformization 
are the only resources in finally effecting the healing of such wounds. 
Kdnig has seen 16 cases of inoculation-tuberculosis, following operations 
for tubercular disease of bones and joints, and 2 such cases have been 
described by Kraske. Czern}^ reports 2 cases in which tuberculosis fol- 
lowed in wounds treated by Reverdin's method of skin-grafting. In 
both instances the patients were healthy, and the skin-transplantation 
was made during the treatment of extensive burns. The skin was 
taken from limbs amputated for tubercular affections. In both cases 

30 



4C6 PRINCIPLES OF SURGERY. 

tuberculosis of the adjacent joint occurred, and in 1 of them tuberculosis 
of the granulating surface. A number of cases of inoculation-tubercu^ 
losis following circumcision are on record, in which the infection often 
occurred in the practice of orthodox Jews, who performed the operation 
in accordance with the directions laid down in the Mosaic laws. The 
loose connective tissue of the prepuce, richly supplied with lymphatics, 
is an admirable surface for absorption, and, when infectious material is 
brought in contact with it, furnishes the most favorable conditions for 
the production of local lesions and the transportation of microbes along 
the lymphatic channels to more distant parts. 

Lehmann has observed 10 cases of inoculation-tuberculosis in 
Jewish boys, caused by sucking the wound after ritual circumcision 
by a phthisical person. Ten days after the circumcision the wound 
became the seat of ulceration, and the inguinal glands began to enlarge. 
Four of the children died of tubercular meningitis, and 3 died after a 
prolonged illness caused by multiple tubercular abscesses. Hofmokl has 
reported a similar case, and Weichselbaum detected the bacillus of 
tuberculosis in the circumcision wound. 

Elsenberg has described 3 cases of tubercular infection after circum- 
cision. All the cases were infants, and the disease appeared primarily in 
the wound or cicatrix, and, later, in the inguinal glands. Local treat- 
ment b} r scraping proved successful. The diagnosis was corroborated 
by microscopical examinations of the granulation tissue. Willy Meyer re- 
lates a case in which circumcision was performed according to the rules 
of the Jewish Church eight da} r s after birth b} T an old man, and in 
which four weeks after the ceremoii}^ an induration appeared at the 
frenulum, and the inguinal glands about the same time began to enlarge. 
Sj T philis was suspected, and the little patient was put on a specific course 
of treatment. The inguinal glands suppurated, and another small ab- 
scess formed in the right gluteal region. The diseased tissue about the 
glans penis was then excised. Microscopical examination of the granu- 
lations revealed the presence of miliary tubercles and bacilli in great 
abundance. The above cases furnish abundant and convincing proof of 
the possibility of the transmission of tuberculosis by cutaneous inocu- 
lation through superficial abrasions, small wounds, and granulating sur- 
faces, and this subject is deserving of the most careful attention of 
surgeons in the matter of prophylaxis, diagnosis, and treatment. 

HISTOLOGY OF TUBERCLE. 

A tubercle-nodule is an aggregation of cells primarily invisible to 
the naked e}'e, the product of a minute focus of inflammation, caused by 
the presence of the essential cause of tuberculosis. When the nodule 



HISTOLOGY OF TUBERCLE. 467 

becomes so large that it can be recognized without the aid of the micro- 
scope, it already consists of a confluence of a number of minute micro- 
scopic nodules. Lsennec described four varieties of tubercle : 1. Miliary 
tubercle, where the visible product of tubercular inflammation appears 
as nodules the size of a millet-seed, of a grayish color, and usually 
arranged in groups. 2. Crude tubercle, where the miliary nodules have 
become confluent and have undergone caseous degeneration. 3. Granular 
tubercle, where the nodules are extremely small, nearly the size of a 
millet-seed, and scattered uniformly through a whole organ. The}' are 
not arranged in groups and have no tendency to become confluent. In 
the centre they become transformed into yellow tubercle. 4. Encysted 
tubercles, or such as are constituted of a hard mass of crude tubercle in 
the centre surrounded by a firm fibrous capsule. These varieties only 
represent different phases of the same process and different stages of 
inflammation produced by the same cause. The anatomico-pathological 
basis of tubercle was created by Virchow, and has been firmly established 
through the laborious researches of Langhans, Wagner, Klebs, Schuep- 
pel, Rindfleisch, Koester, Friedlander, Fox, Baumgarten, and many others. 
The specific-cell theory has had many able advocates, and has been the 
subject of many animated discussions, but it has at last been abandoned 
as fallacious and unscientific. There are no specific tubercle-cells. 

Lebert's tubercle-corpuscle is a thing of the past, and is only re- 
ferred to as a landmark in the history of tuberculosis. Reinhart showed 
that these cells, which were regarded by Lebert as characteristic and 
pathognomonic of tubercle, could be found in all products of chronic 
inflammation, and their presence was only an evidence that a certain 
amount of inflammation existed. When we speak of a tubercle, we 
mean a nodule or granule, which is composed of leucocytes derived from 
the capillary vessels damaged by the bacillus of tuberculosis, or new 
cells derived from tissue proliferation of pre-existing cells acted upon by 
the same cause. The anatomical character of the nodule consists not in 
the presence of any particular cell-element, but in the peculiar arrange- 
ment of the cells ; and this feature is the only reliable anatomical guide 
in making a diagnosis by the use of the microscope. The product of 
tubercular inflammation occurs either in the form of submiliary, micro- 
scopic granules, visible miliary nodules, or a cheesy infiltration, which 
may occupy an entire organ, as a lymphatic gland, or large, isolated foci, 
as in bone. Eveiy tubercular product commences as submiliaiy nodules, 
which, when they become confluent, are transformed into visible gray 
miliary nodules, which again coalesce after they have undergone caseous 
degeneration from cheesy masses, which may be either small and circum- 
scribed or large and diffuse. 



468 PRINCIPLES OF SURGERY. 

Yirchow defines tubercle as a nodule representing a heterogeneous 
growth, a product originally necessarily of a cellular nature, taking its 
starting-point from the connective tissue or from other mesoblastic struc- 
ture, as marrow, fat, or bone. He asserts that the microscopic or sub- 
miliary granule contains all of the essential histological elements of 
tubercle, and by aggregation forms the ordinary miliary nodule of 
Lsennec. When the nodules become confluent they may form masses the 
size of a walnut, surrounded by a common zone of embryonal tissue. 
The yellow tubercle, the crude tubercle of Lsennec, is a more advanced 
stage of the gray, the histological elements of the latter having under- 
gone caseation. 

HISTOGENESIS OF TUBERCLE. 

Colberg asserts that tubercles in the lungs originate from the 
nuclei of the capillary vessels and the connective tissue, the epithelial cells 
lining the alveoli never being primarily affected. Bastian observed 
tubercle-nodules upon the small vessels in cases of basilar meningitis, 
but refers their origin not to proliferation of the nuclei of the endo- 
thelial lining of the vessels, but to new cells springing from the endo- 
thelial cells of the perivascular lymphatic sheaths which surround the 
vessels of the meninges of the brain. 

Knauff demonstrated the lymphoid character of the adventitia by 
examining the capillary vessels of the visceral pleura in dogs which had 
been exposed for a long time to an atmosphere impregnated with coal- 
dust. He found the pigment lodged in small masses close to the walls 
of small arteries and veins. Examining the same vessels in other dogs 
not thus treated, he found upon the outer surface of the adventitia 
opaque, whitish-gray nodules, surrounded by round and oval cells, con- 
taining nuclei, also lymph-corpuscles. The same structures, which he 
named lymph-nodules, are also found around the same vessels of the 
pleura in man, and Knauff looks upon these lymphoid structures as the 
starting-point of tubercular inflammation. 

Klebs maintains that the endothelial cells of lymphatic vessels are 
the most frequent location for the formation of the primary tubercle- 
nodule. He observed that in cases of tubercular ulceration of the intes- 
tines the peritoneum is reached through the lymphatic vessels. Silver- 
stained preparations of inoculation-tuberculosis in rabbits showed that 
the most recent products occurred in the interior of the lymphatic vessels 
at points of intersection. In some places the nodules extended into the 
tissues between the lymphatic vessels, but their centre always corre- 
sponded to the location of a lymphatic vessel. At some points the 
nodules were seen to branch out, but these projections, in realit}', were 
within the lymphatic vessels, as the net-work of lymphatic endothelia 



HISTOGENESIS OF TUBERCLE. 469 

could be seen above and underneath the tubercular product. Toward 
the centre of the nodule no endothelial cells could be distinguished, and 
this fact led him to the belief that the endothelial cells are directly con- 
cerned in the production of the new tissue. In the mesentery he saw 
the tubercles adhere to the outer wall of the capillary vessels, and, as 
the spindle-shaped cells of the outer coat appeared to be pushed apart by 
the new tissue, he regards the adventitia as a genuine lymphoid struc- 
ture. Rindfleisch traces the beginning of the process in miliary tuber- 
culosis of the lungs to a proliferation of the enclothelia and the external 
connective-tissue layer of the capillary lymphatic vessels. Edward 
Smith believes in the epithelial origin of tubercle. Manz studied the 
development of tubercle in the choroid in patients suffering from general 
miliaiy tuberculosis. So constantly does this disease show itself in this 
structure that von Graefe, Cohnheim, Frankel, and Bouchut recommend 
ophthalmoscopic examination as a diagnostic measure in cases of sus- 
pected pulmonary or general tuberculosis. Manz traces the commence- 
ment of the disease in the choroid to cell-pullulation in the tunica adven- 
titia of the small vessels. The process is, however, not limited to this 
structure ; the non-pigmented stroma-cells may also assist in furnishing 
material for the new product. Barth, on the other hand, asserts that the 
vessels, in cases of tuberculosis of the choroid, are not primarily 
affected ; according to his observations, the process depends exclusively 
on a degeneration of the stroma-cells, as the remaining tissue did not 
appear affected. 

Cohnheim, Ziegler, and others maintain that the leucocytes furnish 
most of the material in the building up of the tubercle-nodule. 

Experiments on animals, as well as microscopic examinations of 
pathological specimens, have sufficiently demonstrated the fact that the 
tubercle-nodule is nothing more nor less than a circumscribed inflamma- 
tory product, the histological elements of which are composed of new 
tissue, formed by proliferation of fixed tissue-cells which have come in 
contact with the bacillus of tuberculosis or its ptomaines. The specific 
pathogenic effect of the bacillus consists in its power to cause a chronic 
inflammation of the tissues in which it has localized or with which it has 
been brought in contact. The tissues affected are the cells which are 
nearest the essential microbic cause, irrespective of their embiyological 
origin, their histological structure, or physiological function. In cases 
of inoculation-tuberculosis the primary nodule develops at the point of 
insertion of the virus from connective-tissue proliferation, and from here 
the bacilli enter the lymphatic channels, and the secondary nodules are 
composed of cells derived from the endothelial, lymphoid, and connective- 
tissue cells which compose these structures. If the bacilli are injected 



470 PRINCIPLES OF SURGERY. 

in sufficient quantity directly into the circulation or gain entrance into 
the blood-current from some tubercular focus, they become implanted 
upon the wall of distant capillary vessels, and the nodule which forms at 
the seat of implantation consists of cellular elements formed by the 
tissues of the vessel-wall. As soon, however, as bacilli reach the extra- 
vascular tissues, the}', in turn, furnish their part of the material for the 
further growth of the nodule. If the tubercle bacillus become implanted 
upon a mucous surface, as the bladder, intestines, nose, larynx, uterus, 
etc., if such surface is susceptible to tubercular infection, the epithelial 
cells take an early and active part in the inflammatory process. From 
the manner of entrance into and diffusion through the tissues, it is 
apparent that the mesoblastic tissues, the connective-tissue and endo- 
thelial cells, being the first to become infected, furnish the greatest 
amount of material in most tubercular lesions ; but all tissues, when 
infected, take part in the process. 

HISTOLOGICAL STRUCTURE OF TUBERCLE. 

The essential histological elements which make up a primary tubercle 
nodule are : (a) leucocytes ; (b) giant cells ; (c) epithelioid cells ; (d) 
reticulum. 

Leucocytes. — One of the convincing proofs of the inflammatory 
nature of tuberculosis is the presence of leucocytes in the tubercle 
nodule. The bacillus of tuberculosis appears to exercise only a mild 
pathogenic effect on the capillary wall, and the primary inflammatory 
product is always scant}'. As the colorless blood-corpuscle can only 
escape, in considerable number, through inflamed capillary walls which 
have undergone alteration from the action of some specific microbic 
cause, it is evident that its migration into the paravascular tissues, where 
it forms a part of the tubercular product, can only occur after such 
alteration has taken place from the action of the bacillus upon the 
cement-substance of the endothelial lining of the capillary vessels. The 
leucocytes are found scattered among the other cellular elements, and are 
found in greatest abundance toward the periphery of the nodule. (Fig. 
147.) The leucocytes invariably undergo degenerative changes, and are 
never transformed into other forms of cells found in the tubercular 
product. They have been described as lymphoid corpuscles. Although 
constantly present, they are most numerous when the process is acute. 

Giant Cells. — A great deal has been said and written concerning the 
origin and diagnostic value of the giant cells in the tubercle nodule. 
They resemble the giant cells found in some forms of sarcoma, and 
appear to be simply certain cells which have outgrown others by taking 
up a greater amount of nourishment in the shape of leucocytes which 
have undergone fragmentation. 



HISTOLOGICAL STRUCTURE OF TUBERCLE. 



471 



The giant cells, or, as Klebs calls them, macrocytes, are finely gran- 
ular, and contain multiple nuclei, which usually occupy the periphery of 
the cell, or are arranged in a crescent at one end. In tubercular lesions 
artificially produced in animals the giant cells contain numerous bacilli, 
which occupy, as a rule, the peripheral zone of the cells. In tuberculosis 
in man the bacilli in these cells are never so numerous, and as central 
degeneration of the cells appears they disappear in this portion of the 
cell, while some may still be found in the peripher} 7 . During the progress 
of the disease the giant cell becomes more and more fibrous toward the 
periphery, at the expense of the protoplasmic part in the centre. The 
protoplasm evidently is transformed into or secretes the fibrous margin. 




Fig. 147.— Tubercle Nodule in Lymphatic Gland, x 500. 

A, multinuclear giant cell ; B, epithelioid cells ; C, leucocytes and lymphoid corpuscles. 

If caseation does not take place the bacilli disappear, and the whole cell 
mass, including the giant cells, is converted into a cicatricial mass. 

The first evidences of degeneration appear in the centre of the giant 
cells, and, according to Weigert, they consist of structural and chemical 
changes which are indicative of coagulation necrosis. 

In a recent tubercle nodule the giant cells occupy the central por- 
tion, around which the epithelioid cells and leucocytes are arranged. 
The vacuoles are necrotic foci within the cells. 

The giant cell found in tubercular tissue has its prototype in 
normal tissue. Giant cells were first discovered in normal tissue (mar- 
row of bone) by Robin, who called them myeloplaques. They were sub- 



472 



PRINCIPLES OF SURGERY. 



sequently accurately described by Virckow. In a normal condition they 
are constantly found in bone and the placenta. They are also found 
occasionally in fat-tissue, especially in cases of rapid emaciation. Kun- 
drat has found them in inflamed serous membranes, and Strieker and 
Heitzmann in the inflamed cornea. They are always found around for- 
eign bodies, becoming encysted in the tissues. Friecllander found them 
present in the alveoli of the lungs in cases of chronic pneumonia. 

Heubner found giant cells in endarteritis, Baumgarten in gummata, 
Buhl and Jacobson in granulating wounds, and finally Johne and Pfliio- 
in actinomycotic foci. The histological source of these cells in tuber- 
cular affections has been traced to epithelial cells by Zielonko and 




Fig. 148.— Giant Cell from Centre op Tubekcle of Lung. X 450. (Hamilton.) 

A, granular protoplasmic centre ; B, peripheral more-formed part ; C, crescent of nuclei; 
D, endothelium-like cells ; E, two vacuoles within the giant cell. 



Weigert ; to endothelial cells by Kundrat, Klebs, Herrenkohl, and Zie- 
lonko ; to connective tissue or endothelial cells by Yirchow, Fleming, 
and Ziegler. Schueppel and Rindfleisch believe that they invariably 
originate within blood-vessels or lymphatics, where these authors regard 
them as the first step toward the development of tubercle nodules. 
Ziegler claims to have seen giant cells develop from white blood-corpus- 
cles. Hering, Aufrecht, Woodward, Schueller, and Treves are of the 
opinion that what appear as giant cells in tubercular tissue are not cells, 
but only represent spaces which correspond to transverse sections of 
lymphatic channels, the protoplasm representing the coagulated lymph 
within these vessels, and what appear as nuclei being enlarged, swollen 



HISTOLOGICAL STRUCTURE OF TUBERCLE. 



473 



endothelial cells. Giant cells possess amoeboid movements, and by 
virtue of these they are capable of taking up in their protoplasm fine 
particles, such as microbes, pigment material, and blood-corpuscles, 
which have undergone fragmentation. The giant cells in tubercular 
lesions are hyperplastic, epithelioid cells, and consequently are derived 
from the same histological source as these. 

Epithelioid Cells. — Cells intermediate in size between the giant cells 
and the leucocytes are found in every tubercle nodule in which the cells 
have not been destro} r ed by caseation. These cells were first described 
by Rindfleisch, and were called by him epithelioid cells from their struct- 
ural resemblance to epithelial cells. Klebs calls them platycytes. 




Fig. 149.— Tuberculosis of Trochanteric Bursa, x 200. 

A, A, A, A, giant cells ; B, caseous contents of bursa ; C, epithelioid cells and leucocytes. 



They are about two or three times larger than a white blood- 
corpuscle, and in shape they are either round or somewhat elongated. 
In structure they are finely granular, and contain one large and often a 
number of small nuclei. The} 7 form the bulk of all recent nodules, are 
scattered between the giant cells, and are often arranged in layers around 
them. The histological source of these cells was supposed to be the 
leucocyte by Schueppel, Ziegler, and Treves ; the endothelial cells of the 
lymph-spaces by Aufrecht, Hering, and Woodward ; the endothelial cells 
of the blood-vessels and lymphatics or connective-tissue cells b}- Rind- 
fleisch and nearly all of the modern authors. The epithelioid cells 



474 PRINCIPLES OF SURGERY. 

are the embryonal cells, the product of proliferation from any of the 
fixed tissue-cells in a tubercular lesion, and they remain as such until 
they are destroyed by degenerative changes from the continued action 
upon them of the bacillus of tuberculosis or its toxins, or until, on 
cessation of the primary cause, they are transformed into tissue of 
greater durability. 

Reticulum. — Schueppel first called attention to the reticulated 
structure of tubercle b} T his description of the reticular arrangement 
within tubercles of lymphatic glands. 

The reticulum, according to most authors, consists of the pre- 
existing connective tissue pushed asunder by the new cells. According 
to Wagner, Schueppel, Brodowski, Thaon, and Ziegler, it is made up of 




Fig. 150. -Section from Mucous Membrane of Pharynx, showing Epithelioid Cells 
with A few Small Giant Cells. X 350. (Birch-Hirschfeld.) 

protoplasm. Buhl taught that the giant and epithelioid cells secrete a 
substance at their periphery which, on becoming firm, is formed into a 
structure resembling connective tissue. According to his researches 
only the marginal zone is supplied with loose, ready-formed, connective 
tissue of the organ. Wahlberg maintained that the principal reticulum 
consists of protoplasm which is traversed by a net-work of connective 
tissue. The reticulum is always more marked in the periphery of the 
tubercle-nodule, where, from pressure, it is condensed into a fibrous 
capsule (Fig. 151, C). 

Arrangement of the Cells in a Recent Tubercle-Nodule. — The earliest 
evidence of the formation of a tubercle-nodule, as witnessed under the 
microscope, is the appearance of small cells which resemble ordinary 



HISTOLOGICAL STRUCTURE OF TUBERCLE. 



475 



embryonal cells, which are the product of tissue proliferation from a 
mesoblastic matrix, usually the connective tissue, and its embryological 
and histological prototype, the endothelial cells of blood-vessels and 
lymphatics. From these cells the epithelioid and giant cells are, later, 
developed. Some of the central cells, by appropriation of a superabund- 
ance of food furnished by leucocytes in a state of fragmentation, become 
hyperplastic, and are transformed into giant cells ; these occupy the 




Fig. 151.— Fully-Developed Reticular Tubercle of Lung. X 450. (Hamilton.) 

A, A, A, giant cells; B, vacuole in one of these: C, peripheral capsule of fibrous tissue; D, reticulum 
of the tubercle ; E, large endothelium-like cells lying on the reticulum and within its meshes ; F, smaller 
" lymphoid " cells occupying the same situation ; G, peripheral fibrous-looking border of the giant cells. 



centre of the nodule. Around these cells the smaller or epithelioid cells 
arrange themselves, and between them and in the periphery of the nodule 
are found the smallest cells, — the leucocytes. 

Gaule and Tizzoni distinguish three zones in a tubercle : (1) an 
external, composed of small round cells ; (2) a lesser, epithelial, or 
middle zone, containing the reticulum ; (3) a central space containing a 
giant cell. The structure of a tubercle is not always typical, and hence 
the division into zones is based more on theoretical grounds than actual 



476 PRINCIPLES OF SURGERY. 

observation. The giant cell is not an essential histological element of 
tubercle, bat an accidental product. In some tubercles giant cells can- 
not be found, while in others they are numerous. Giant cells can only 
develop from epithelioid cells if the local conditions are favorable for 
hypernutrition ; that is, if the leucocytes in a condition of fragmentation 
are within their reach. If they are present they always mark the loca- 
tion of the starting-point of the tubercular infection, as only the older 
epithelioid cells undergo this change. The number and size of the 
epithelioid cells are also subject to great variation, and are modified by 
the nutritive conditions within and in the immediate vicinity of the 
nodule. If cell proliferation is active the epithelioid cells appear densely 
packed in the reticulum, nutrition is greatly impaired, and the new 
cells undergo degenerative changes before they attain their average size. 
The leucocytes are scattered among the giant and epithelioid cells, and, 
as they reach the part through the inflamed wall of the capillaries in the 
immediate vicinity, they are most numerous in the periphery of the 
nodule and along the course of the affected vessels. 

GROWTH OF THE TUBERCLE-NODULES. 

The t}^pical tubercle-nodule is microscopic in size. The growth of 
the swelling depends on the formation of new tissue, migration of leuco- 
cytes, and confluence of nodules into larger masses. The bacillus of 
tuberculosis, when brought in contact with fixed tissue-cells susceptible 
to its pathogenic action, incites tissue proliferation, which always takes 
place by kaiyokinesis. Baumgarten's investigations leave no doubt that 
phatycytes constitute the entire mass of the forming tubercle. He has 
also observed karyokinetic figures in tubercular tissue in cells derived 
from the connective tissue, endothelia, and epithelia. The tubercle 
bacilli are found in the interior of giant and epithelioid cells and between 
them. 

Each tubercle-nodule increases in size by the growth of new cell3 
from pre-existing tissue, and as the primary cause, the bacillus of 
tuberculosis, multiplies in the tissues, bacilli are conveyed into the 
surrounding tissues by leucocytes or the plasma-current, and new centres 
for tubercle formation are established, which, later, become confluent, 
forming masses of considerable size, the numerous foci of caseation 
corresponding to the centres of so many nodules. The growth of 
tubercle is favored by local and general conditions which diminish tissue 
resistance, while retardation takes place in consequence of degenerative 
changes in the cells of which it is composed, or, if the cells are converted 
into tissue of a higher type, from disappearance or suspension of activity 
of the primary cause. 



PATHOLOGICAL VARIETIES OF TUBERCLE. 477 

PATHOLOGICAL VARIETIES OF TUBERCLE. 

Several varieties of tubercle have been described, according to the 
histological structure of the tubercle or the structure or condition of the 
cells of which it is composed. 

Reticulated Tubercle. — This is the ordinary form of tubercle usually 
met with, and the most important anatomical feature is the presence of 
a well-defined reticulum, composed of pre-existing connective tissue and 
a delicate net-work of branching giant cells, in the meshes of which are 
found the epithelioid cells and leucocytes. 

Fibrous Tubercle. — In contradistinction to the reticulated or 
lymphoid tubercle, a few years ago the fibrous tubercle was described, 
distinguished by its pearl-like, light-gray appearance, but possessing the 
same inherent tendency to- caseation. It is said to be found most fre- 
quentlj' in dense, fibrous tissue, and quite often in newly-formed connective 
tissue. Histologically it is composed of nodules of dense connective 
tissue, the cells of which have undergone rapid growth, containing, fre- 
quently, more than one nucleus. A further development only takes 
place in the interior of the nodule, as here caseation occurs, the caseous 
focus being surrounded by a firm capsule of connective tissue. The 
description of fibrous tubercle by Langhans differs materially from the 
above. According to investigations of this author, the fibrous tubercle 
has for its favorite location the so-called parenchymatous organs, as the 
lungs, liver, spleen, kidneys, testicles, epididymis, and brain. The larger 
nodules are composed of three zones. The central zone consists of a 
few connective-tissue fibres, free oil-globules, and cells in a condition of 
fattry infiltration. The middle zone is composed of connective tissue. 
As the cells of this zone are not numerous, it presents the appearance of 
a capsule ; in reality, however, it is not a capsule in the proper sense of 
the word, but a matrix of tissue proliferation, from which the central 
part of the tubercle is the offspring. Both Langhans and Schueppel, 
like nearly all of the modern pathologists, regard fibrous tubercle not as 
a distinct special anatomical form, but as an ordinary tubercle in which 
the epithelioid cells in the peripheral zone have been converted into con- 
nective tissue. Fibrous tubercle differs from the ordinary cellular 
variety only in so far that it contains a larger amount of connective 
tissue. If in a tubercle-nodule at the time the 3 T oung cells are yet 
vigorous the primary microbic cause ceases to act, degenerative changes 
fail to take place and the embryonal cells are transformed into connec- 
tive tissue. The cicatricial condition starves out remaining embryonal 
cells ; at the same time an impermeable wall of connective tissue is thrown 
around the primary depot of infection, which effectually guards against 
the escape of active bacilli or their spores into the surrounding tissues. 



478 PRINCIPLES OF SURGERY. 

Hyaline Tubercle. — CMari described another variety of tubercle, — 
the hyaline tubercle. The first specimen in which he found this variety 
was taken from the liver of a tubercular child 4 years of age. The 
nodules in the brain, lungs, and bronchial glands in the same case pre- 
sented the ordinary structure of lymphoid tubercle. The clear hyaline 
structure of those found in the liver gave them a very peculiar appear- 
ance. The change is believed to be due to a lryaline degeneration of the 
reticulum, and resembled most closely the hyaline degeneration of the 
capillaries of the brain. Chiari conjectures that it may be regarded as 
a benign change opposed to caseation, which tends to infection. Hyaline 
degeneration of any pathological product must now be considered as 
one of the earliest phases of coagulation necrosis, and, if a considerable 
area of the nodule undergo this change rapidly and simultaneously, the 
structures will present a hyaline appearance ; but, if the lryaline product 
continue to be acted upon by the same causes, caseation will follow, and 
the hj'aline tubercle becomes a cheesjr tubercle. 

CASEATION. 

The gra}'-, or miliaiy, tubercle is transformed into the yellow, crude, 
or cheesy tubercle b}^ a process which is called caseation, or tyrosis. 
The exact nature of this process remains unknown. The cheesy 
material is composed of the products of cell necrosis. Early death of 
cells is the most characteristic pathological feature of tubercle, which 
distinguishes it from all other forms of chronic inflammation. Two 
causes can be advanced to explain this peculiar and almost pathogno- 
monic form of degeneration, which occurs, almost without exception, in 
every tubercle if a sufficient length of time has elapsed: 1. Inadequate 
blood-supply. 2. Specific action of the bacillus of tuberculosis or its 
toxins. Caseation always commences in the centre of a nodule, con- 
sequently at a point most remote from the vascular supply, and in 
cells which have been exposed longest to the deleterious effect of the 
primary microbic cause. Tubercle is a non-vascular product. From 
causes which, as yet, are not known, the tubercular product is not 
supplied with new blood-vessels. The angioblasts are transformed into 
epithelioid cells that have lost their power of vessel formation. Nodules 
which have primarily an iutra-vascular origin are rendered avascular by 
closure of the vessel from intra- and peri- vascular cell proliferation. If 
the primary starting-point is outside of the vessels, the rapidly accumu- 
lating cells exert pressure upon the surrounding vessels, and thus 
diminish the blood-supply to the part affected. The new cells require 
an adequate blood-supph r for their further development, and if this fail 
to take place, as is the case in every tubercular product, they necessarily 



CASEATION. 



479 



suffer from malnutrition, and undergo degenerative changes at an early 
stage of their existence. A deficient blood-supply, in the absence of 
other causes, would result in fatty degeneration of the new tissues ; but 
caseation is something different from ordinary fatty degeneration, and 
the bacillus of tuberculosis or its toxins must be regarded as its 
immediate and essential cause. Caseation is preceded by coagulation 
necrosis, which is one of the results of the specific action of the bacillus 
on the tissues. The coagulation necrosis commences in the giant cells, 
and in the epithelioid cells in the centre of the nodule, and caseation 
follows as soon as the dead cells have lost their histological identity 



A - 




Fig. 152.— Tuberculosis of Trochanteric Bursa, x 500. Recent Area of Invasion, 

SHOWING BliOOD-VESSELS. 
A, A, blood-vessels ; B, B, giant cells ; C, C, epithelioid cells. 



and appear under the microscope as a debris in which no distinct cell 
forms can be identified. Caseation is attended by softening, whicli can 
be readily recognized in tubercular masses the size of a hazel-nut to that 
of a walnut, composed of numerous confluent nodules with as many 
caseating foci. 

In such masses the small, cheesy cavities become confluent and form 
spaces of considerable size. Caseation proceeds from tbe centre of each 
nodule toward the periphery, layer after layer of epithelioid cells being 
desti'03'ed and changed into cheesy material. The part of a tubercle 
nodule whicli has undergone caseation contains few or no bacilli, and 
yet inoculation experiments show it to be highly infectious. The cheesy 



480 PRINCIPLES OF SURGERY. 

material does not furnish the proper nutrient material for the growth 
and development of the bacillus, which dies from starvation, while the 
spores, being more durable and possessing greater power of resistance, 
remain in an active condition for an indefinite period of time in the dead 
material, and it is due to their presence that infection takes place from 
cheesy foci, and that successful inoculations can be made with cheesy 
material. While the disease has become arrested in the centre of a 
nodule, with the appearance of caseation, its growth in a peripheral 
direction pursues the same relentless course. The bacilli multiply in 
fresh tubercular tissue, and are carried beyond the peripheral zone 
into the surrounding tissues, where new, independent foci of infection 
are thus established, which, in the course of time, pass through the same 
series of pathological changes as the primary nodules. It is a well- 
known clinical fact that acute miliary tuberculosis is not a primary affec- 
tion, as in all such cases a careful post-mortem examination will reveal 
the presence of a cheesy focus in a lymphatic gland, the lungs, testicles, 
a joint, or bone, or some other organ from which the infection occurred. 
Weber found cheesy foci in 16 cases of tuberculosis of serous mem- 
branes. The cheesjr mass may lie latent so long as it is solid, but as 
soon as it liquefies the spores which it contains can be taken up by the 
blood-vessels and become the cause of general infection. 

CALCIFICATION. 

One of nature's means in preventing the local extension of tubercle 
and in guarding against regional and general infection is calcification of 
the tubercular product. This can only occur as a secondary condition 
in tubercles that have undergone caseation. Calcification implies the 
removal of the cheesy material and the substitution for it of inorganic, 
calcareous material. It is a process which greatly resembles petrifaction. 
Arrest of the tubercular process b}' caseation and calcification frequently 
takes place in the lungs, and, occasionally, in the lymphatic glands. 



CHAPTER XIX. 

Clinical Forms of Surgical Tuberculosis. 

It is but a few years since it was thought impossible that any other 
organ than the lungs should be the seat of tuberculosis. The different 
forms of surgical tuberculosis that will be described below were not cor- 
rectly understood until quite recently, and consequently a rational sur- 
gical treatment was out of question. Most all of the localized tubercular 
processes were included under the general term scrofula, and were 
regarded as local manifestations of a general d}^scrasia, and treated in 
accordance with this view of their patholog}^ The discovery of the 
bacillus of tuberculosis has rendered the word scrofula obsolete, and has 
assigned to the tubercular processes in the various organs and tissues of 
the body their correct etiological and pathological significance, and 
paved the way for their successful surgical treatment. There is hardly 
a tissue in the body which may not become the primary seat of tuber- 
cular infection, or which escapes when diffuse dissemination occurs 
through the medium of the general circulation. The frequency of 
tubercular affections is something appalling. At least 1 person out of 
ever} T 1 dies of some form of tuberculosis. Most of the large hospitals 
contain from 25 to 50 per cent, of patients afflicted with this disease. 
The ravages of the disease are to be seen everywhere, in the shape of 
disfiguring scars of the neck, deformed limbs, and bent spines. Health 
resorts, frequented for years by tubercular patients, have become infected 
to such an extent that there is great danger of the whole population 
becoming exterminated by this disease. The sources of infection in such 
places have become so numerous that it is unsafe to breathe the air, to 
drink the water, or to eat the food prepared in houses which for }'ears 
have been hot-beds for the bacillus of tuberculosis, and b}^ persons car- 
rying the microbe upon ever}' square inch of their surface. That whole 
communities and nations, where this disease has been prevalent for cen- 
turies, have not been completely depopulated long ago is owing to the 
fact that many persons possess, from the time of their birth, a degree 
of resistance to infection that even direct infection by inoculation 
would prove harmless. The bacillus is not the sole, but the essential, 
cause of tuberculosis. 

31 (481) 



432 PRINCIPLES OF SURGERY. 

HEREDITARY AND ACQUIRED PREDISPOSITION. 

Almost every author recognizes, as an important element in the 
etiology of tuberculosis, the existence of a hereditary or acquired pre- 
disposition. Little is known in reference to the real nature of such a 
predisposition. A weakness of the lymphatic vessels in scrofulosis was 
recognized by Sylvius as early as 1695, by Portal in 1690, and still later 
by Bell, Percival Pott, Hufeland, and Broussais. Fox is of the opinion 
that a disposition to tuberculosis is created by certain anatomical or 
physiological defects in the lymphatic system. The cause of scrofula 
was ascribed b}^ Yirchow to a weakness or imperfection in the arrange- 
ment of the lymphatic system ; by Hueter to a dilatation of lymph- 
spaces ; and by Billroth to a constitutional anomaly. Mordhorst regards 
a sluggish circulation, the consequence of superficial, imperfect respira- 
tion, by causing capillary stasis and favoring inflammatory exudation, a 
potent factor in producing that peculiar vulnerability of the tissues in 
scrofulous subjects. Rokitansky placed great stress on the importance 
of an imperfect circulatory and respiratory apparatus as a predisposing 
cause of tuberculosis. In 1871 Friedlander suggested that in cases of 
tuberculosis there might be present, and active, a fusion of the scrofu- 
lous and tubercular diathesis, — a view which was indorsed by Charcot in 
1877. Aufrecht claims that the disposition to the origin of tubercle 
ma}^ be found in the lymphatic vessels. Riedel defines the hereditary 
predisposition to tuberculosis as consisting in a peculiar defect in the 
anatomical arrangement of the tissues, especially of the lymphatic 
glands, which furnish a favorable soil for infection. Schiiller believes 
that the noxse of tuberculosis excite a slow form of inflammation, with 
a tendency to speedy retrograde metamorphosis of the new material. 
Quincke recognized a close relationship between scrofula and tubercu- 
losis, when he says : " Scrofulous persons are especially predisposed to tu- 
berculosis ; tuberculosis hardly ever occurs except in scrofulous persons." 
Ziegler was aware that pulmonaiy phthisis is the most frequent cause of 
death in scrofulous patients. Whittaker, in comparing the etiology of 
tuberculosis with syphilis, makes use of the following very positive 
language : — 

" There' is no such a thing as a predisposition to either disease. 
Either a man has syphilis, or he has it not. One man is not more pre- 
disposed to either disease than another. Sj^philis affects one individual 
more than another because its virus finds a better lodgment upon 
mucous membrane. Tuberculosis finds, also, fortuitously, a better nidus 
in one case than another. The virus of tuberculosis is lodged, in one 
case, and not coughed up, just as in syphilis the virus is secreted and 
not washed off." And again : " From any chancre, plaque, gumma, or 



HEREDITARY AND ACQUIRED PREDISPOSITION. 483 

other deposit of syphilis, re-absorption may take place at any time, and 
re-infection with syphilis ; or, better, re-appearance of external signs. 
So, from any caseous nodule, wherein the tuberculous virus is locked up 
in temporary innocence, absorption may take place under favoring cir- 
cumstances, and a new outbreak of tuberculous symptoms appear, the 
quantity of virus thus set free determining, to a great extent, perhaps, 
the virulence of the symptoms. While the virus is thus locked up, the 
disease is latent; when set free, it is manifest." Wynne Foot says: 
" Tubercles are small-celled overgrowths of lymphatic tissue that have 
preserved such uniformity of size, color, and shape as to have long 
suggested the probability of their lymphatic origin." Wilson Fox 
regarded tubercle as an overgrowth or hyperplasia of lymphatic tissue 
resulting from irritation of the lymphatic elements. 

Savory, in speaking of the relation of scrofula to tubercle, remarks: 
" It appears to me that there is nothing sufficient to warrant the patho- 
logical distinction which it is now the fashion to make between scrofula 
and tubercle." And further: " Tubercle may be said to be the essential 
element of scrofula." According to Rokitansky, the most frequent seat 
of tubercle in children is in the lymphatic glands. Yirchow maintained 
that scrofula constitutes the basis of tubercle, and that in man tubercu- 
losis depends in general on scrofula. He asserts, further : " On account 
of the histological identit}^ of the scrofulous and tubercular new growths, 
it is often impossible, in a given tubercular lesion, to determine how 
much is inflammatory and how much is tubercular." From the above 
quotations it becomes apparent that nearly all of the older authors 
recognized, if not the identity, at least a close relationship between 
scrofula and tuberculosis. The identity of scrofula and tuberculosis was 
established not upon anatomical or pathological researches, but was 
definitely settled by the discovery of the same cause in the local lesions 
of both. Clinical and experimental proof is accumulating rapidly, estab- 
lishing the fact that heredity in the causation of tuberculosis often means 
direct transmission of tubercle bacilli from parents to child. Birch- 
Hirschfeld and Schmore have reported the case of a young woman who, 
early in her first pregnancy, presented signs of pulmonary phthisis, to 
which she succumbed in the seventh month. Immediately after the 
death of the mother the foetus was removed by Caesarian section. Post- 
mortem revealed tuberculosis not only in the lungs, but also in other 
organs of the mother. Although the foetus had been alive shortl} r before 
the death of the mother, it was dead when removed. Careful examina- 
tion of the foetus showed no macroscopical tubercular lesions. The sur- 
face of the abdomen was washed with a solution of bichloride of mercury 
and the cavity opened with sterilized knives. Small fragments of the 



484 PRINCIPLES OF SURGERY. 

internal organs were implanted into the abdominal cavities of two 
guinea-pigs and a rabbit. One of the guinea-pigs died in fourteen days. 
The other was killed at the end of six weeks, and many tubercles were 
found in the peritoneal cavity. The rabbit lived for three months. On 
its death many tubercles were found in the liver and lung. Tubercle 
bacilli were found in the umbilicus and in the blood of the umbilical vein 
of the foetus. The demonstration of any definite anatomical defect, 
hereditary or acquired, which acts as a predisposing cause to tubercular 
infection, has, so far, not succeeded. Only a few years ago Formad made 
some interesting studies concerning the histological structures of tissues 
that are known to be prone to tubercular infection, and he believed that 
the changes constantly found were such that favored the arrest of 
migrating cells. It is more probable that the hereditary or acquired 
predisposition to tuberculosis, which must now be recognized as an 
important element in the causation of the disease, must be regarded rather 
as a diminution of the power of resistance inherent in the tissues to the 
action of the specific microbic cause than any characteristic anatomical 
cell defects. From a clinical stand-point, it is important to remember 
that in the causation of tuberculosis we must recognise a combination 
of etiological factors, viz.: (1) local or general conditions, resulting 
from hereditary or acquired causes, which diminish the resisting capacity 
of the tissues to the action of the bacillus of tuberculosis, which must 
be regarded as the predisposing cause; and (2) the presence in the 
tissues of the essential cause of the disease, — the bacillus of tuberculosis. 
The predisposing cause can under no circumstances result in tuber- 
culosis without action of the essential cause, and the bacillus of tubercu- 
losis is most certain to produce its specific pathogenic effect in tissues 
debilitated by hereditary or acquired causes. The different avenues 
through which infection takes place will be referred to in the further 
discussion of the subject which heads this chapter. 

TUBERCULAR ABSCESS. 

Pathological Anatomy. — The effect of the bacillus of tuberculosis on 
the tissue is to produce a chronic inflammation, which invariably results 
in the production of granulation tissue. The embryonal cells furnish, as 
it were, a wall of protection for the surrounding healthy tissue. The 
characteristic pathological feature of every tubercular product consists 
in the tendency of the cells of which it is composed to undergo early 
degenerative changes, which are caused by local anaemia and the specific 
chemical action of the toxins of the tubercle bacilli, and consist in 
coagulation necrosis, caseation, and liquefaction of the cheesy material 
into an emulsion, which has always been regarded as pus until recent 



TUBERCULAR ABSCESS. 485 

investigations have shown that it is simply the product of retrograde 
tissue metamorphosis, and not true pus. I believe that it can now be 
considered as a settled fact that the bacillus of tuberculosis is not a P3 T o- 
genic microbe, and that, in the absence of other microbes, it produces a 
specific form of chronic inflammation, which invariably terminates in the 
formation of granulation tissue ; and that, when true suppuration takes 
place in the tubercular product, it occurs in consequence of secondary 
infection with pus-microbes. The so-called tubercular, or cold, abscess 
contains a fluid which macroscopically resembles pus, but which, when 
examined under the microscope, shows none of its histological elements. 
If the bacillus of tuberculosis meet with sufficient resistance on the 
part of the surrounding tissues, it finally exhausts the nutrient material 
in the granulations and dies, or remains in a latent condition ; the granu- 
lation material is converted into cicatricial tissue and the local lesion is 
cured. The cases in which the tubercular product is removed by cica- 
trization terminate most frequently in spontaneous cure. If, on the 
other hand, bacilli in sufficient number are present to destroy the granu- 
lation cells, coagulation necrosis, caseation, and liquefaction of the in- 
fected tissue take place ; a spontaneous cure is still possible if a part 
of the fluid portion is absorbed and the solid debris becomes encapsu- 
lated. The same favorable termination is expedited under similar cir- 
cumstances if the primary lesion have healed and the inflammatory 
product is removed by operative interference under the strictest anti- 
septic precautions, or if, at the same time, the primary focus can be 
completely removed by extending the operation to the primary lesion. 
Secondary infection of a tubercular product with pus-microbes without 
a direct infection-atrium is possible, and if the primary lesion is located 
in an unimportant organ, and in such a place where the inflammatory 
product can be early reached or can be discharged spontaneously, a cure 
is often effected, as the suppurative inflammation may destroy all of the 
tissues inhabited by the bacillus, and the whole nidus, with the microbes 
it contains, is eliminated permanently from the body. Such a course is 
not infrequently observed in cases of tuberculosis of the lymphatic 
glands of the neck. If, however, the tubercular process affect important 
organs or parts deeply located with extensive infection of tissue, and 
secondary infection with pus-microbes take place, then the patient 
incurs the danger of septic infection and local and general dissemina- 
tion of the tubercular process from the breaking down of the protective 
wall of granulation tissue. That the bacilli do not grow in a tubercular 
abscess has been definitely settled by Schlegtendal. He examined 520 
specimens of fluid from tubercular abscesses, and found bacilli present 
in only 75 per cent. Garre has also made an extended series of observa- 



486 PRINCIPLES OF SURGERY. 

tions to ascertain the presence of the bacillus in cold abscesses. Accord- 
ing to this author, many tubercular ulcerations and abscesses are the 
result of a mixed infection, as has been claimed by Hoffa for some cases 
of empyema complicating pulmonary or pleural tuberculosis. In cold 
abscesses, and in the liquefied cheesy material of tubercular cavities in 
bone, no pus-microbes could be found ; not even in cases that pursued a 
rapid course. Cultivations of such material remained sterile, while 
inoculations produced t} r pical tuberculosis. Such specimens, examined 
under the microscope, showed none of the morphological elements of pus, 
but were seen to consist of an emulsion composed of fat-globules and 
detritus of broken-down tissue suspended in serum. 

Garre believes it is possible that, in many cases of suppuration fol- 
lowing in the course of a tubercular process, pus is the result of a mixed 
infection, and that the pus-microbes disappear before the examination is 
made. 

Tavel has examined the inflammatory product of 40 cases in which 
a positive or at least probable diagnosis of tuberculosis was made, before 
operation, for evidences of mixed infection, by means of microscopical ex- 
amination of stained preparations under the microscope, cultivation and 
inoculative experiments. In 30 he found the tubercle bacillus exclusively, 
in 5 tubercle bacilli and pus-microbes ; the latter, however, had no 
hematogenic source, as their entrance into the tubercular focus through 
a communication between it and the internal or external surface of the 
body could be traced. In the last 5 cases he found no tubercle bacilli, 
but a mono-infection with pus-microbes which had produced a lesion 
resembling tuberculosis. He believes, with Garre, that tubercular 
abscesses are caused exclusively by tubercle bacilli, but he assigns to 
these pyogenic properties. He maintains that the chemical products of 
the tubercle bacillus transforms leucocytes and embi^yonal cells from the 
fixed tissue-cells into pus-corpuscles, which, however, show an earlier 
tendency to fatty degeneration and granular degeneration than pus- 
corpuscles in the pus of acute abscesses. 

Prudden and Hodenpyl killed tubercle bacilli by prolonged boiling, 
and still found them markedly chemotactic. When introduced in con- 
siderable number into the subcutaneous tissue, or into the pleural or 
abdominal cavities, they are distinctly pyogenic, causing aseptic localized 
suppuration. Under these conditions the}' are capable, moreover, of 
stimulating the tissues about the suppurative foci to the development 
of a new tissue closely resembling the diffuse tubercle tissue induced by 
the living germs, but this tissue manifests no tendenc}' to caseation. 

The walls of the tubercular cavity contain the tj^pical structure 
of the tubercular lesion and the primary and essential cause of the in- 



TUBERCULAR ABSCESS. 487 

fiammation, the bacillus tuberculosis. The infection follows the migra- 
tion of the abscess in whatever direction that may take place. If an 
additional infection from without take place, following either a spon- 
taneous discharge or after incision, the superficial granulations are 
destroyed by the suppurative process which is initiated, exposing the 
patient to the additional risks of septic infection and a more rapid local 
and general dissemination of the tubercular process. 

Symptoms and Diagnosis. — The tubercular abscess is called a cold 
abscess because it lacks the characteristic clinical phenomena which 
attend the development of an acute or hot abscess. There is but little, 
if any, rise of the local temperature, and, unless the abscess has reached 
the skin, the surface looks rather preternaturally pale than red, and the 
abscess itself is always painless and not tender on pressure. The pain, 
if present, is referred to the primary seat of the tubercular inflammation. 
Fluctuation is usually well marked, as the tissues around the abscess are 




Fig. 153. — Membrane Lining Tubercular Abscess. (Landerer.) 

not much infiltrated. The most important clinical feature of a cold 
abscess is its tendency to wander from the place where it originated to 
distant localities by gravitation ; hence the name given to it by German 
writers, — Senkungsabscess. Thus, in tubercular spondylitis, the abscess 
may appear in the lumbar region, and is then called lumbar abscess; it 
may follow the iliac muscle and appear in one of the iliac regions, and is 
then called iliac abscess; or, finally, it may follow the psoas muscle and 
appear above or below Poupart's ligament, when it constitutes a psoas 
abscess. > 

Iu tuberculosis of the hip-joint the abscess appears posteriorly 
underneath the gluteal muscles, if perforation of the capsule in this 
direction take place; or it appears anteriorly a considerable distance 
below the hip-joint, if perforation of the capsule take place in an oppo- 
site direction. As the contents of the abscess carry the original cause 
of the disease, infection of the tissues takes place along the whole course 



488 PRINCIPLES OF SURGERY. 

of the abscess, which is always lined with infected granulation tissue. 
Although the primary cause of a tubercular abscess is most frequently a 
tuberculosis of a joint or bone, it can also develop in the course of any 
localized form of tuberculosis, and it is quite frequently met in the course 
of tuberculosis of the lymphatic glands. The diagnosis must be made 
with special reference to the nature and location of the primary lesion. 
In tuberculosis of the spine the fixed pain in the region of the affected 
vertebrae, radiating from here in the direction of the nerves on each side, 
is an important symptom, and this symptom is always aggravated by 
flexion and ameliorated by extension of the spine. In coxitis the pain 
in the beginning of the disease is usually referred to the inner aspect of 
the knee-joint, but is alwa3 r s increased by motion in the hip-joint. In 
cold abscess, caused by glandular tuberculosis, the clinical history will 
point to a chronic inflammation of the glands which preceded the forma- 
tion of the abscess. As soon as the abscess reaches the skin that struct- 
ure becomes inflamed, livid, and more and more attenuated by pressure 
and inflammation, until spontaneous perforation takes place at a point 
subjected to greatest pressure. If a tubercular product become the 
seat of a secondary infection with pus-microbes, the subsequent symp- 
toms, local and general, are those of suppurative inflammation. The 
temperature, which was normal, or nearly so, increases and presents the 
daily curves indicative of suppuration, while the abscess, which has been 
painless heretofore, becomes painful and tender on pressure ; in fact, a 
chronic inflammation has been supplanted by an acute one, with a cor- 
responding change of the clinical picture. If any doubt remain as to 
the character of the swelling and the nature of its contents, this can be 
dispelled at once by resorting to an exploratory puncture. In cold 
abscess the fluid removed presents the appearance of serum in which 
minute particles of broken-down tissues are suspended, while in an 
abscess caused by a mixed infection it presents the macroscopical and 
microscopical appearance of pus. 

Prognosis. — The danger attending tubercular abscess must be esti- 
mated exclusively by the extent and location of the primary disease and 
the presence or absence of tuberculosis in other organs. If the general 
health remain unimpaired, even an extensive local tubercular disease may 
be amenable to a spontaneous cure or successful surgical treatment. On 
the other hand, a tubercular abscess developing in the course of an 
insignificant and unimportant local lesion occurring in an anaemic person, 
the subject of incipient multiple foci in different organs, must be regarded 
as a formidable condition, with little or no prospects of a favorable ter- 
mination. I have learned to regard pronounced anaemia as an unfavor- 
able symptom in the different forms of surgical tuberculosis, as it is often 



TUBERCULAR ABSCESS. 489 

an expression that general infection has occurred. Another important 
matter to be taken into consideration, in making a prognosis in cases 
where general infection can be excluded, is the possibility of eradicating 
the primary lesion by operative interference. Where this can be done, 
the chances of successful treatment of the local disease are much better ; 
at the same time, the removal of all the infected tissues is the best 
guarantee against general infection. Other things being equal, the prog- 
nosis is better in patients without an hereditary history of tuberculosis, 
and in young persons than those advanced in years. 

Treatment. — The surgical treatment of large tubercular abscesses is 
always fraught with danger from the fact that, even if conducted under 
strict antiseptic precautions, it is not always possible to prevent infec- 
tion with pus-microbes. Large tubercular abscesses were a " nole me 
tangere " to the older surgeons, as it was well known evacuation by 
incision would be followed within a few days by hectic fever, profuse 
sweating, diarrhoea, and other symptoms of septic infection. The early 
advocates of the antiseptic treatment hoped that the time had come 
when the surgeon had it in his power to prevent septic infection during 
the operation by resorting to the necessary antiseptic precautions, and 
to maintain an aseptic condition throughout the after-treatment under 
an efficient antiseptic Irygroscopic occlusive dressing. If we remember 
that in cases where the abscess originated from a primary lesion inac- 
cessible to direct treatment it may require months for the healing 
process to be completed, it is not surprising that even the strictest 
antiseptic precautions in the hands of the ablest surgeons have failed 
in protecting the abscess-cavity against septic infection for such a long 
time. 

In a number of tubercular abscesses originating from a tubercular 
focus in the vertebra, in the hip- and knee- joints, I have succeeded in 
preventing infection, and the patients were cured after several months 
of the most careful and watchful treatment ; but in a greater number of 
cases infection occurred at the time of operation, or weeks or months 
later during change of the dressing, or in consequence of a slipping of 
the dressing. In abscesses in the gluteal or inguinal regions, especially 
in children treated by incision and drainage, it is almost next to im- 
possible to maintain an aseptic condition for weeks and months, and the 
most careful and laborious efforts in this direction will often result in 
failure. 

(a) Evacuation by Tapping followed by Antiseptic Irrigation and 
Subcutaneous lodoformization. — The frequency with which failures have 
occurred after incision and drainage, in the hands of the most enthu- 
siastic followers of the antiseptic treatment, has again aroused the fear 



490 PRINCIPLES OF SURGERY. 

of surgeons in attacking large tubercular abscesses by incision and 
drainage, and the subcutaneous evacuation with subsequent disinfection 
of the abscess-cavity has again come into favor. That iodoform exerts 
an inhibitory effect on the growth of the bacillus of tuberculosis is now 
generally accepted. Its use in the treatment of tubercular affections is 
almost universal. It has been extensively used for injection into tuber- 
cular abscess, after evacuation by tapping, since Bruns advocated this 
treatment in 1887. It was first used dissolved in ether in the proportion 
of 1 part to 20. The ethereal solution has the advantage of bringing 
the drug in contact with every part of the interior of the cavity by the 
distention which takes place from the expansion of the ether when 
exposed to the bod} r -temperature, but the injection is usually followed 
by considerable pain. Bruns used a suspension of iodoform in glycerin 
and alcohol. Recently the following formula was suggested by 
Krause : — 

Iodoformi subt. pulveris, 50.0 

Mucil. gurami Arab., 23.0 

Glycerini, 83.0 

Aquae destillatse, q. s. ad 500.0 

(Ten-per-cent. iodoform mixture.) 

A safer and equally efficient preparation is a simple 10-per-cent. 
mixture of iodoform in glycerin, which has been used for a number of 
years with such marked success in the surgical clinic of Rush Medical 
College, Chicago. The emulsion is sterilized by boiling. 

The evacuation of the abscess is to be done with an ordinary trocar 
under strict antiseptic precautions. The surface of the abscess is thor- 
oughly disinfected in the usual manner, and the instrument rendered 
aseptic by boiling. The trocar is inserted in such a manner that a track, 
at least an inch in length, is made underneath the skin before the instru- 
ment is plunged into the abscess-cavity, in order to make the wound, 
after the removal of the instrument, as nearly as possible subcutaneous. 
As tubercular abscesses usually contain shreds of dead connective tissue 
and masses of broken-down granulation tissue, the evacuation is often 
attended by a considerable difficult}^, as these substances block the open- 
ing of the instrument and thus prevent evacuation. The simplest pro- 
cedure to overcome these difficulties is to introduce through the canula a 
small hook made by bending an aseptic wire, and to extract with it any 
substance which interferes with the escape of the fluid contents. Gentle, 
uniform pressure is of great value in expediting the escape of the con- 
tents and preventing the entrance of air. Iodoformization of the 
abscess-cavity is not to be done until complete evacuation of solid de- 
tached particles has been effected by means of irrigation with a 3-per- 



TUBERCULAR ABSCESS. 



491 



cent, solution of boric acid. This can be readily done with the injection 
syringe here illustrated. A sufficient quantity of fluid is allowed to 
flow into the cavity until this is distended as much as before the evacua- 
tion of the fluid, when, by gentle pressure, it is forced out through the 
canula. By filling and emptying the cavity alternately in this manner a 
requisite number of times, complete evacuation of the fluid and loose 
solid contents is effected, and the cavity is now ready for iodoformization. 
The iodoform injection is made with the same syringe. Whatever 
formula for the solu- 
tion is selected, not * £ 
more than half a i / 

drachm of the iodoform 
should be injected at 
the first time, and in 
children even less. If 
this dose does not 
produce any unpleas- 
ant symptoms, it may 
be increased the next 
time the operation is 
repeated. There seems 
to be very slight dan- 
ger of iodoform intoxi- 
cation, not even a 
symptom of this being 
observed in 109 cases 
thus treated by Brims, 
of Tiibingen. If the 
ethereal solution is 
used, the iodoform will 
become diffused over 
the entire inner sur- 
face of the abscess- 
cavity; but, if a non-evaporating medium for the mixture is used, this 
must be done by gently kneading and rubbing the parts over the 
abscess after the canula is withdrawn. The injection containing the 
iodoform is, of course, intended to remain in the cavity. The puncture 
in the skin is closed with collodium, and the walls of the abscess are 
kept in contact by compress and bandage. Absolute rest is to be 
enforced for sometime by splints or confinement in bed, according to the 
location of the abscess. The operation is to be repeated in the course of 
a week, or as soon as the abscess-cavity has partially refilled. The treat- 




Fig. 154.— Senn's Injection Syringe. 



492 PRINCIPLES OF SURGERY. 

ment of tubercular abscesses by subcutaneous evacuation, with subse- 
quent iodoformization, should be adopted and repeated, from time to 
time, in all cases where the primary lesion is inaccessible to radical surg- 
ical treatment, and ma}^ yield good results in cases which heretofore had 
been subjected to heroic surgical treatment from the beginning. It may 
also prove useful as a preparatory treatment in cases which subsequently 
require operative treatment. If the iodoform prove beneficial, seldom 
more than three injections are necessary ; the most reliable sign of its 
curative effect is increased viscidity of the contents of the abscess at 
each successive tapping. Iodoform has no curative influence in tuber- 
cular affections complicated by mixed infection with pus-microbes. 

(b) Incision and Removal of Primary Focus. — In all cases where the 
iodoform treatment is inapplicable or has failed, and where, from the ana- 
tomical location of the primary lesion, it is possible to remove the tuber- 
cular product by operative interference, and the patient is free from other 
tubercular affections, a radical operation is absolutely indicated. In such 
cases the abscess-cavity is laid freely open in a direction which will secure 
most ready access to its interior with least injury to surrounding parts. 
After the abscess has been opened its contents are washed awaj^by irrigat- 
ing with an aqueous solution of iodine, after which the granulations lining 
the cavity are scraped out with a sharp spoon and the primary lesion is 
removed in a similar manner. In dealing with such cavities it is impor- 
tant not to forget that the granulations contain tubercle bacilli, and, if 
they are not thoroughly removed, the principal object of the operation 
— removal of the primary cause — has not been accomplished, and a 
return of the disease is to be expected. If the abscess communicate 
with a primary focus in a bone, it is advisable to resort to ignipuncture 
of the bone after the cavity has been cleared of the granulations with 
the sharp spoon. The wound is then iodoformized and closed in 
the usual manner, leaving only a small opening at the most dependent 
point for drainage. The scraped surfaces are now in the same conditions 
for primary union as a recent aseptic wound, and, if kept in accurate 
apposition by the antiseptic dressing, which answers at the same time 
the purpose of a compress, primary union throughout is frequently ob- 
tained. Abscesses which have opened spontaneously, or during the 
treatment of which infection has occurred, must be treated on the same 
principles as acute abscesses. As far as can be done, the suppurating 
granulations should be removed with the sharp spoon and efficient 
tubular drainage established, and by frequent antiseptic irrigations an 
attempt is made to prevent septic infection. Landerer has recently called 
attention to the value of balsam of Peru in the treatment of tubercular 
affections. He claims that this drug acts beneficially bj' stimulating the 
tissues to renewed activity, thus neutralizing, at least to a certain degree, 



TUBERCULOSIS OF THE INTERNAL EAR. 493 

the pathogenic effect of the bacilli. Sayre, of New York, has used this 
remedy for more than thirty years in the treatment of tubercular joints, 
and his results have certainly been extremely satisfactory. In the treat- 
ment of open, suppurating, tubercular cavities, the balsam of Peru should 
be tried as a local application. As a fluid for irrigation under the same 
circumstances nothing can surpass the efficacy of a strong aqueous solu- 
tion of tincture of iodine or a 1-per-cent. solution of trichloride of iodine, 
(c) General Treatment. — Patients suffering from suppurating tuber- 
cular cavities require nutritious food, ale, porter, or some of the substantial 
wines ; out-door air will often prove the best tonic. Change of residence 
to the sea-shore or some mountain resort has often been known to effect 
a cure when recovery was despaired of as long as the patients lived in 
localities less favorably located. In the way of medication the treatment 
must be purely symptomatic. The prolonged use of 5-drop doses of 
guaiacol has a decidedly beneficial effect in the treatment of all forms 
of tuberculosis. Appetite is restored by the use of bitter tonics ; 
anaemia is treated by the administration of some mild preparation of 
iron, as the syrup of iodide of iron, tincture of chloride of iron, albu- 
minate of iron, or citrate of iron. If codliver-oil is given it should be 
administered pure, and not in emulsion, and never upon an empty 
stomach. The pale Norwegian oil is the best. The best time to give 
the oil, without disturbing the digestion, is an hour or an hour and a 
half after each meal, in doses of from a teaspoonful to a tablespoonful, 
according to the condition of the digestion and the age of the patient. 

TUBERCULOSIS OF THE INTERNAL EAR. 

That an ordinary otitis media with perforation of the tympanum 
may occasionally be transformed into a tubercular lesion by the entrance 
of tubercle bacilli there can be no doubt. A number of cases of primary 
tuberculosis of the middle ear have been reported and several cases have 
come under the personal observation of the writer. Habermann has 
recently investigated this subject by examining, post-mortem, 18 tuber- 
cular subjects, in whom either otorrboea or deafness, without active dis- 
charge, had been observed during life, and in 9 of these he could demon- 
strate the presence of tubercular lesions in the auditoiy canal. In 1 
case he found, in the left auditory apparatus, tuberculosis of the entire 
middle ear where the tympanum was intact. In another tubercular 
subject, a man 38 } T ears of age, in whom tuberculosis of the ear was 
observed a } T ear and a half before death, the post-mortem revealed exten- 
sive tuberculosis of the cochlea, in the internal auditoiy canal, and in 
the superior semicircular canal, while the other semicircular canals and 
the vestibule were destroyed by caries. Infection with the bacillus 
tuberculosis of granulations in the middle ear through a perforation in 



494 PRINCIPLES OF SURGERY. 

the tympanum can occur in persons otherwise in perfect health. The 
diagnosis in such cases can be readily made by removing fragments of 
granulation tissue for microscopic examination. If they are found to 
contain tubercle bacilli a positive diagnosis has been made, and no time 
should be lost in resorting to a radical operation. The removal of the 
infected granulations with a sharp spoon, followed by irrigation with a 
warm 3-per-cent. solution of boric acid and iodoformization of the cavity 
are the measures to be employed in removing the infected focus and in 
preventing extension of the disease into other parts of the ear, the 
mastoid cells, or the meninges of the brain. 

TUBERCULOSIS OF THE IRIS. 

Inoculations of the anterior chamber of the eye with tubercular 
material have shown the extreme susceptibility of the iris to tubercular 
infection. That this structure should occasionally become the seat of 
primary infection is evident from a case reported by Griffith. The 
patient was a female child 7 months old. The eye had been affected for 
one month ; there was an enlarged gland in the neck on the same side, 
but there were no other physical signs of tubercle; no history of 
heredit} T . A yellowish nodule grew from the periphery of the iris of the 
right eye, and numerous millet-seed-like bodies from its surface; the 
pupil was closed, but there was no acute inflammation. The local disease 
increased rapidly in extent. The e}^e was enucleated after three weeks' 
treatment. The disease was found to be confined to the iris and ciliary 
body. Under the microscope the new growth showed the characteristic 
structure of tubercle. In 32 recorded cases, in which microscopic and 
bacteriological tests left no doubt as to the tubercular nature of the 
disease, only 1 eye was affected in 29. The average age of the patients 
was 12 years; youngest 4 months, oldest 51 }^ears. In 10 cases bacilli 
were searched for, but only found in 4 ; in 1 of the remaining 6 cases, 
however, the inoculation test was successful. A number of patients 
recovered completely and permanently after enucleation. 

If the tubercle is located on the anterior surface of the iris, a diag- 
nosis can usually be made without much difficulty at an earlv stage, as 
the inflammatory product can be seen and carefully examined through 
the transparent cornea. If some doubt exist at first as to the nature 
of the swelling, this is soon set aside by the progress of the disease. The 
primary nodule soon becomes surrounded and covered by an eruption 
of miliary tubercles. The disease here, as elsewhere, shows its charac- 
teristic clinical feature, — progressive extension, affecting all the struct- 
ures contiguous to or continuous with the part primarily affected, 
irrespective of their anatomical structure. Glandular infection on the 



TUBERCULOSIS OF THE SKIN. 495 

same side is an early and quite constant occurrence. Even if the disease 
is correctty diagnosticated at an early stage, complete removal by iridec- 
tomy is impossible, as parts of the iris which present a perfectly normal 
appearance may already be infected and lead to an almost certain recur- 
rence of the disease. Enucleation of the affected eye is only justifiable 
if the disease affect only one eye, and if the surgeon can satisfy himself 
that the patient is not suffering at the same time from tuberculosis in 
other organs inaccessible to successful surgical treatment. 

TUBERCULOSIS OF THE SKIN. 

All forms of primary tuberculosis of the skin are the result of direct 
inoculation with tubercle bacilli. Considering the frequency with which 
abrasions occur in the exposed portion of the skin, and the innumerable 
sources of infection with the virus of tuberculosis, it is somewhat strange 
that primary tubercular lesions of the skin are not of more frequent 
occurrence. Baumgarten believes that this is due to the slow growth of 
the bacillus and the dense structure of the deeper portions of the skin, — 
conditions which enable the superficial wound to heal before the tubercle 
bacilli have penetrated the tissues to a sufficient depth. Considerable 
confusion exists at the present time in reference to the nomenclature of 
primary tubercular affections of the skin. We find descriptions of what 
is called tuberculosis of the skin, tuberculosis verrucosa cutis, and lupus, 
all of which affections have been proved to be tubercular in their origin 
and manifesting the same clinical tendencies. It is time that these imma- 
terial and unimportant distinctions should be set aside, and these different 
affections should be included under one head, as primary tuberculosis of 
the skin, since all of them present the same histological structure, and all 
are caused by direct inoculation with tubercle bacilli. 

Riehl and Paltauf have described an affection of the skin, under the 
name of tuberculosis verrucosa cutis, in which the bacillus of tuberculosis 
is constantly found, and which they attributed to local infection, because 
all of the patients they examined were persons handling animal products. 
Riehl has also shown the tubercular nature of papillomatous affections 
occurring upon the hands of pathological anatomists by finding the 
bacillus in the tissues. 

Anatomical and Clinical Proofs of the Tubercular Nature of Lupus. 
— Lupus vulgaris, and probably the other varieties of this affection of 
the skin, are nothing more nor less than cases of cutaneous inoculation- 
tuberculosis. It is well known that lupus occurs most frequently in 
parts of the body most exposed to injury and infection ; that is, in the 
skin not protected by the hair or clothing. Lupus attacks most fre- 
quently the nose, face, eyelids, ears, and hands, localities where abrasions 



496 PRINCIPLES OF SURGERY. 

occur most frequently, and parts upon which floating microbes are too 
liable to become deposited, and where direct inoculation with soiled 
hands, handkerchiefs, and towels is most likely to occur. I shall quote 
from a number of reliable authorities at sufficient length to prove that 
lupus and tuberculosis are identical affections. From a clinical stand- 
point Hebra brought the different varieties of lupus under one common 
head. He separated it entirely from syphilis, but otherwise did little 
to fix its pathological significance. He adopted the classification of 
Fuchs and the older French and English authors, who taught that it was 
one of the manifestations of scrofula, and that anatomically it was 
composed of granulation tissue. 

Yirchow classified it with the granulomata, but denied its identity 
with scrofula. Rindfleisch described it as a proliferation of epithelial 
cells, — as a sort of phthisis cutanea. Hueter, who, in his pathological 
views, was generally far ahead of his time, affirmed that it was a form of 
fungous inflammation, the specific cause of which, when introduced into 
the organism, produced miliarj- tuberculosis. Volkmann included it among 
the affections which anatomically are represented by granulation tissue. 
Friedlander was the first to take a positive stand in asserting that lupus 
is a tubercular affection of the skin, and showed its histological identity 
with other recognized forms of local tuberculosis. He demonstrated the 
presence of miliary tubercles in it. The absence of caseation in lupus, 
which was regarded by some authors, among them Baumgarten, as an 
evidence of its non-tubercular character, has been explained by Schiiller 
as being due to the soil present in and around the nodules. He also 
calls attention to the fact that Cohnheim and Thoma have seen caseous 
foci in lupus, and consequent^ asserts that the absence of caseation is 
no proof of the non-tubercular nature of lupus. 

Neisser accepts fully and pleads strongly in favor of the tubercular 
nature of lupus. Rassdnitz collected 209 cases of lupus, and found that 
in 30 per cent, of all the cases it was associated with other evidences 
of tuberculosis. He placed, also, great importance on the observations 
that lupus is prone to develop in the scar left after healing of a localized 
tuberculosis in Lymphatic glands, and that lupus is often observed 
upon the nose or eyelids in cases of chronic nasal or conjunctival ca- 
tarrh. In 10 to 15 per cent, of his cases lupus could be traced to heredi- 
tary predisposition. Demme observed miliary tuberculosis in 2 of his 
cases after scraping lupus. Pontoppindau asserted that, in his expe- 
rience, in 50 to 75 per cent., patients suffering from lupus manifested ad- 
ditional evidences of tuberculosis. Quinquaud saw in 3 cases of lupus 
pulmonaiy tuberculosis appear as a final cause of death. Of 38 cases 
that came to the personal knowledge of Bessnier, 8 of them suffered 



TUBERCULOSIS OF THE SKIN. 497 

from pulmonary phthisis. Of 2 patients treated by Aubert, 1 died of 
acute pulmonary tuberculosis and the other of tubercular pleuritis after 
scarification. 

Renoward was able to ascertain the existence of pulmonary phthisis 
in 50 per cent, of his cases of lupus. Block met with tuberculosis in 
other organs, before or after the development of lupus, in 114 out of 
144 cases. Bender examined 3*74 cases of lupus. In 159 of these an 
accurate history could not be obtained. In 99 of the latter number 
symptoms of other antecedent or co-existing tuberculous lesions existed. 
In TT of the cases tuberculosis in an etiological or clinical aspect was 
present. Leloir observed several cases in which, after years, a lupus of 
the face gave rise to a pseudo-erysipelatous swelling of the face, which 
disappeared after a time, to be followed by swelling of the submaxillary 
lymphatic glands, which remained stationary. Soon after the affection 
of the lymphatic glands had appeared, febrile disturbances, gastric s}^mp- 
toms, and evidences of pulmonary infiltration followed. In all of these 
cases Leloir believes that the virus of tuberculosis had left the primary 
location, and had migrated through the lymphatic vessels and glands into 
the lungs. In 10 out of his 1*7 cases the tubercular nature of lupus was 
clinically manifest. Sachs ascertained that, of 105 cases of lupus which 
he collected, in 86 per cent, the patients had co-existing tuberculosis in 
other parts of the body, or a hereditary predisposition to tuberculosis 
could be shown to exist. 

Experimental and Bacteriological Evidences of the Tubercular Nature 
of Lupus. — If the clinical and anatomical proofs which have been 
advanced to establish the tubercular nature of lupus point unequivocally 
in that direction, the crucial test is furnished by the inoculation experi- 
ments and bacteriological investigations that have been made with the 
same object in view. Koch, in his paper on the etiology of tuberculosis, 
states that he produced a pure culture of the bacillus tuberculosis from 
a case of lupus which resembled in every respect the cultures obtained 
from recognized tuberculosis, and with the fifteenth generation from this 
source, one year after the first cultivation, he inoculated 5 guinea-pigs 
by subcutaneous injection and produced typical tuberculosis in all of 
them. Doutrelepont found in 7 cases of lupus the bacillus tuberculosis 
invariably present, in greater or less number, either within the cells or 
dispersed in small groups between them. He never found them in the 
interior of giant-cells, but in their immediate vicinity. In a second 
communication the same author reports 18 additional cases of lupus, in 
each of which the presence of the bacillus could be demonstrated in the 
tissues. Demme detected the bacillus in 6 cases of lupus. Pfeiffer 
found it in a case of lupus of the conjunctiva. Schuchardt and Krause 

32 



498 PRINCIPLES OF SURGERY. 

discovered the bacillus in 3 cases of lupus affecting, respectively, the 
face, ears, and leg. In examinations made of 11 cases of lupus by Cornil 
and Leloir, and 4 by Koch, for the especial purpose of showing the 
identity of lupus and tuberculosis, the bacillus was found in every 
instance. In the artificial tuberculosis of animals, produced by implanta- 
tion of lupus-tissue, the specific microbe was shown to exist by Pagen- 
stecher, Pfeiffer, Koch, and Doutrelepont. To prove that lupus and 
tuberculosis are identical, it became necessary to furnish the necessary 
experimental proof, and to show the uniform presence of the bacillus of 
tuberculosis in the lupus-tissue, all of which has been done with almost 
infallible positive results. The inoculation experiments with lupus- 
tissue have already been referred to, and from them it can be learned 
that, with few exceptions, they were followed by positive results ; that 
is to say, implantation of lupus-tissue into subcutaneous tissue or the 
peritoneal cavity, in animals susceptible to tuberculosis, gave rise to 
local tuberculosis at the point of implantation and to dissemination of 
the process in a manner characteristic of tuberculosis in man. A diffuse 
tuberculosis of the skin and mucous membranes, occurring as a sort of 
secondary localization in patients suffering from advanced tuberculosis, 
has been recently described by Pantlen, Bizzozero, Baumgarten, Chiari, 
Hall, Jan i sch, Riehl, Yidal, and Finger. As such cases occur in conse- 
quence of auto-infection in persons debilitated by the ravages of the 
primary disease in the lungs, it is not surprising that the skin affection 
should extend more rapidly than in cases of primary tuberculosis of the 
skin. 

Pathology and Morbid Anatomy. — As every case of tuberculosis of 
the skin is caused by the entrance of tubercle bacilli from without 
through some infection-atrium, the primary pathological changes occur 
at the point of inoculation. As soon as the bacilli reach the vascular 
layers of the skin, a nodule forms which contains the histological ele- 
ments described in the section on the Histology of Tubercle. By the 
formation of new nodules, a more diffuse cellular infiltration of the 
tissue between them, the lesion tends to spread, and, by confluence of the 
infiltrated portions, a dense and more or less extensive area of nodular 
infiltration maybe formed. If the continuity of the epidermic laj'er of 
the skin has been restored after infection has occurred, and the cell pro- 
liferation has been abundant, the swelling may resemble a papillomatous 
growth, and, on account of the increased vascular supply, an excessive 
production and exfoliation of epidermis over the infiltrated area occur. 
These are the cases of inoculation-tuberculosis which have been described 
as tuberculosis verrucosa cutis. The nodules undergo disintegration 
near the centre, and the epidermis at a corresponding point becomes 



TUBERCULOSIS OF THE SKIN. 499 

macerated and detached, leaving at first a minute defect, which secretes 
a serous fluid. 

As soon as the underlying granulation tissue has been exposed 
to infection from without, infection with pus-microbes occurs, and 
the destruction of tissue is hastened by the suppurative inflammation 
which follows, as the granulation cells are rapidly destined bj 7 the 
pus-microbes and their toxins, and are eliminated as pus-corpuscles. 
Ulceration now takes the place of the papillomatous growths, and the 
defect increases in size as rapidly as granulation tissue is produced by 
the action of the bacillus tuberculosis. New nodules are produced in 
the immediate vicinity of the ulcer, which are again dissolved b} 7 retro- 
grade tissue metamorphosis of its cellular constituents and purulent 
liquefaction. It is not uncommon to find, at some places, efforts at repair, 
and even partial cicatrization and epidermization ; but the disease pursues 
its relentless course in other directions, and, after what appears as health} 7 
new tissue, becomes again infected and the process of destruction is 
repeated. In some forms of tuberculosis of the skin the infection 
remains superficial, and only the more superficial portions of the skin 
undergo pathological changes characteristic of tuberculosis ; while in 
other cases the process extends deeper and deeper, until muscles, 
fascia, and bone are destroyed by the disease, in the manner of its exten- 
sion from tissue to tissue resembling the clinical behavior of malignant 
tumors. In this manner the whole nose, ej-elids, and the greater portion 
of the face are frequently destined before the patient is relieved from 
his sufferings by a merciful death. Microscopical examination shows 
the lesions to consist in the formation of granulation tissue, in which 
the typical structure and histological elements of tubercle can be readily 
recognized. Caseation is seldom found, probably on account of the 
location of the tubercular product so near the surface of the skin, and 
also because the granulation tissue soon becomes the seat of a secondary 
infection with microbes which prevent caseation. Inmost cases a well- 
marked reticulum is present between the new cells, and these are often 
grouped in masses around the blood-vessels. 

Symptoms and Diagnosis. — Tuberculosis of the skin is most fre- 
quently met with in middle-aged persons, but no age is exempt from it, 
as I have seen it in children 5 } 7 ears of age and in persons far advanced 
in years. It attacks most frequently the nose, e} r elids, cheeks, ears, and 
hands, but it ma} r also develop upon the different parts of the trunk. 
The disease commences in the form of a small, red, vascular nodule ; is 
not painful nor tender on pressure. In the vicinity of this nodule new 
foci spring up, and by confluence may form a swelling of considerable 
size. To the touch these nodules impart rather a sensation of elasticity 



500 PRINCIPLES OF SURGERY. 

than hardness, and if the swelling is large in size an obscure sense of 
fluctuation may be felt. Before ulceration takes place the surface of the 
nodules is covered by a thickened epidermis, which can be scraped off in 
white scales. If no ulceration take place (lupus non-exedens) , the 
nodules may remain stationary in size for an indefinite period of time or 
undergo a spontaneous cure by cicatrization, during which the epithelioid 
cells are converted into connective tissue. Ulceration begins over the 
centre of the nodule, at a point where the nutrition of the tissues is 
most impaired by pressure, and extends from here toward the margins 
of the nodule, attacking the new nodules almost as fast as they are 
formed (lupus exedens). Cicatrization and ulceration are often seen 
side by side. Ulceration is hastened by the secondary infection with 
pus-microbes, which invade the granulation tissue in the margins of the 
ulcer, occupying the tubercular zone. Repair by cicatrization and epi- 
dermization is more likely to occur if the infection remains superficial, 
but is usually entirely absent as soon as the tubercular process has ex- 
tended beyond the limits of the skin. The differential diagnosis as to 
tuberculosis of the skin, tertiary syphilis, and epithelioma is generally 
very difficult, and sometimes almost impossible. There is very little 
difference between the histological structure of a tubercle-nodule and a 
gumma, and the most experienced microscopist is liable to make a mis- 
take if called upon to make a diagnosis exclusively by the use of the 
microscope. 

The history of the case is of the greatest importance in making a 
differential diagnosis between tuberculosis and syphilis. If the patient 
is positive that he never contracted syphilis, it is still possible that the 
lesion may be syphilitic, as the disease may have been inherited ; if he 
give a history of primary and secondary syphilis, the affection may still 
be tubercular; but a straight history of tuberculosis or S3 7 philis will go 
far in determining the nature of the local affection. If any doubt remain 
this can be cleared up by the use of the microscope, and, if this fail in 
the course of five weeks, either by the effect produced by antisyphilitic 
treatment or the result of inoculation experiments made by implantation 
of fragments from the inflammatory product into the subcutaneous 
tissue in guinea-pigs. The microscopic examination of fragments of 
tissue removed for this purpose must have in view the detection of the 
bacillus of tuberculosis, which is constantly present in tubercular tissue. 
The specimen must be prepared by double staining according to Ehrlich's 
method, and if the affection is tubercular, the bacillus can be found by 
making a patient search for it ; if it is syphilitic, it will, of course, be 
absent. The bacilli, however, may be so few that even a careful search 
of stained specimens may result negatively, and in such a case a positive 



TUBERCULOSIS OF THE SKIN. 501 

diagnosis can often be made by observing the effects of a thorough, anti- 
syphilitic treatment. For an adult, ■£■■$ grain of corrosive sublimate with 
15 grains of potassic iodide, dissolved in distilled water, is given four times 
a da}'', — after each meal and at bed-time. If the lesion is syphilitic, a de- 
cided improvement will be observed in the course of two or three weeks ; 
if tubercular, this treatment will make no decided impression on the local 
lesion. The most reliable diagnostic test in diflerentiating between 
tuberculosis of the skin and a syphilitic lesion consists in removing, 
under antiseptic precautions, a fragment of granulation tissue the size 
of a small pea, and implanting the same into the subcutaneous tissue of 
a guinea-pig. 

Tavel has been studying, in a systematic manner, the diagnostic 
value of implantations of tubercular material in animals, mainly guinea- 
pigs. He found that fragments of granulation tissue, taken from a 
tubercular product and implanted into the subcutaneous connective 
tissue, in the inguinal region in guinea-pigs, invariably produces in this 
animal local, and later general, miliary tuberculosis, and death in from 
five to six weeks. The course of the disease thus artificially produced 
is typical ; at the point of inoculation a hard nodule appears first, the 
result of traumatic response on the part of the tissues around the graft. 
Next, a lymphatic gland becomes enlarged in the immediate vicinity of 
the inoculation and in the direction of the lymphatic stream. Often all 
of the inguinal glands are infected successively. At a later stage the 
axillary glands become affected. At the necropsy it was always observed 
that, of the internal organs, the spleen becomes affected first, then the 
liver and lungs, but before death is produced almost every organ is the 
seat of miliary nodules. When the differential diagnosis between tuber- 
culosis and syphilis cannot be made from a clinical stud}' of the case or 
by the use of the microscope, inoculation experiments will always furnish 
the desired information in from three to six weeks. If the lesion is 
tubercular, the infected guinea-pig contracts the disease, and dies in 
from five to six weeks ; if it is syphilitic, the implantation will prove 
harmless and the animal remains well. The differential diagnosis be- 
tween tuberculosis of the skin and epithelioma must be based on the 
primary location of the pathological product and the character of the 
infiltration. Tuberculosis commences in the vascular portion of the 
skin ; hence, the primary nodule is sub-epidermal ; while epithelioma 
starts in the non-vascular epidermis and infiltrates the deeper layers of 
the skin later. The tubercular nodule is not hard, but somewhat elastic, 
to the touch. The carcinomatous infiltration feels almost as hard as 
cartilage, and forms a part of the epithelial layer of the skin from the 
beginning. A tubercular ulcer of the skin is covered with flabby granu- 



502 PRINCIPLES OF SURGERY. 

lations, and its margins, although infiltrated, do not feel as firm as the 
borders of an ulcerating epithelioma. Under the microscope the tubercle- 
nodule shows granulation cells in the meshes of a delicate reticulum, 
while in a section of an epithelioma a well-marked alveolated reticulum 
can be seen, the meshes of which are occupied by embn-onal epithelial 
cells arranged in concentric layers. Another microscopic criterion is 
the absence of blood-vessels in tubercle-nodules, while carcinoma is a 
vascular structure. 

Prognosis. — Primary local tuberculosis of the skin may lead to 
glandular infection, and, after the last lymphatic filter has been passed, 
to general miliary tuberculosis. The tubercular product in exceptional 
cases becomes the starting-point of carcinoma. The local extension of 
the tubercular process is subject to many variations. In some instances 
the process commences during early life, and remains stationary for 
twenty or more years, when it suddenly commences to extend very rap- 
idly, destroying all of the tissues which come in its way, irrespective of 
their anatomical structure. Tuberculosis of the face, manifesting such a 
tendency to rapid extension, may in a few months destroy nearly all of 
the soft tissues and a considerable portion of the superficial bones, so 
that the head looks more like a skull than the head of a living being. In 
other instances the ulceration keeps extending, while at other points the 
healing process is progressing with equal speed. In such cases the 
massive scars are often productive of the most hideous deformities. 
Recurrence of the disease in the scar-tissue is of common occurrence. 
The prognosis, as far as life is concerned, is favorable so long as the 
disease remains local and does not progress rapidly ; while life is threat- 
ened as soon as regional infection through the lymphatic glands takes 
place, or when ulceration extends rapidly without any tendency to repair 
by cicatrization and epidermization. Tuberculosis of the skin without 
ulceration is a more benign form of the disease than when ulceration has 
occurred, as in the latter case the destructive process is hastened by 
secondary infection with pus-microbes. 

Treatment. — About the only medicine that deserves any confidence 
in the treatment of tuberculosis of the skin is arsenic. This drug can be 
given in the form of Fowler's solution, in doses of from 3 to 10 drops 
after each meal, well diluted with water. It is best to commence with 
the smallest dose and add 1 drop every week until the physiological 
effect is produced, when the use of the medicine is not suspended, but 
the dose is diminished. To be of any use, the medicine has to be con- 
tinued for weeks and months. If the patient is anaemic, it is combined 
with the tincture of chloride of iron, and, if the patient's appetite is poor, 
with one or more of the bitter tonics. If the patient is emaciated, pure 



TUBERCULOSIS OF THE SKIN. 503 

codliver-oil can be given with good results an hour and a half after meals, 
in doses which will be tolerated by the stomach. If digestion is impaired 
this drug should be withheld. A well-selected, nutritious diet is indicated 
in all such cases, with plenty of out-door exercise. Salt-water baths invigo- 
rate the peripheral circulation, and consequently favor the limitation of 
the disease and the process of repair. The surgical treatment of tuber- 
culosis of the skin is to be conducted upon the same principles as opera- 
tion for the removal of malignant tumors. The use of caustics often 
does more harm than good. The great object of the local treatment is to 
remove every particle of the infected tissues, for if this is not done a re- 
currence is almost sure to take place. If the patient object to a radical 
operation, and the tubercular process has gone on to ulceration, all irri- 
tating applications should be avoided and the ulcer protected by a piece 
of lint spread with empl. hydrargyri or unguent, hydrargyri oxj^d. albi. 
Balsam of Peru can also be used with benefit as a local application. If a 
radical operation is decided upon, this should be done preferably by ex- 
cision. Excision should be practiced exclusively in cases where the 
extent of the disease is limited. The incision should be made some 
distance from the visible margins of the infiltration, in order to include 
tissues which, although presenting macroscopically a healthy appearance, 
may already be infected with bacilli, conveyed there by migrating leu- 
cocytes. The greatest care must be exercised in removing the deeper 
portions of the inflammatory product, as this may send down projections 
at different points which it is necessary to remove with the principal 
mass. 

Thiersch's method of restoring the excised skin places the surgeon in 
a position where he can excise an extensive area of integument, and } T et 
obtain primary healing of the wound and perfect restoration of the skin 
under a single dressing. I have, on several occasions, removed tuber- 
cular foci from the face and temporal region the size of the palm of the 
hand, and, by covering the defect at once with large skin-grafts, saw the 
whole healing process completed in two weeks, with almost perfect 
restoration of the lost tissues. In cases where the disease is too exten- 
sive for excision, removal of the infected granulations is attempted by 
the vigorous use of Volkmann's sharp spoon. Skin-grafting can be done 
after curetting in the same manner as after excision, but the knife alwa} r s 
leaves a better surface for skin-grafting than the sharp spoon. If, after 
either operation, the result is not perfect, and the tubercular process 
returns at one or more points, the granulations are again removed with 
the sharp spoon and the defect covered with skin-grafts. Tuberculosis 
without ulceration demands treatment b}^ excision, while in the case of 
ulcerating nodules the choice lies between the knife and sharp spoon, and 



504 PRINCIPLES OF SURGERY. 

to the first preference should be given in all cases where excision can be 
done with a fair prospect of removing all of the infected tissues. The 
constitutional treatment should be continued for several months after the 
local lesion has apparently healed, as the disease is very liable to recur 
at the site of operation. The site of operation should be carefully pro- 
tected against injury a long time after the process of repair has been 
completed, in order to guard against a return of the disease, from local 
irritation preparing the soil for the pathogenic action of latent bacilli 
which may remain incorporated in the scar-tissue. 



CHAPTER XX. 

Tuberculosis of Lymphatic Glands and Peritoneum, 
tuberculosis of lymphatic glands. 

That most cases of chronic inflammation of the lymphatic glands 
are in their origin, course, and final termination instances of local tuber- 
culosis, has been satisfactorily shown by clinical experience, microscopic 
examination, inoculation, and cultivation experiments. 

Manner of Infection and Dissemination of the Bacillus of Tuber- 
culosis. — The tubercle bacilli enter the lymphatic circulation through 
some abrasion or pathological defect of the skin or mucous surface ; any 
loss of continuity of surface may furnish the necessaiy yxtrtio invasioyiis 
for the entrance of the microbes from without. In tubercular affections 
of the skin the point of inoculation becomes the centre of the primary 
nodule, because the bacilli are present in sufficient quantity and viru- 
lence to produce the necessary irritation ; but in tuberculosis of the lym- 
phatic glands the microbes enter the lymphatic channels usually before 
they have caused any visible lesions at the point of entrance. 

Volkmann found tubercle bacilli in the skin of an eczematous fore- 
arm, and it is probable that many cases of tuberculosis of the cervical 
glands in children are caused by the entrance of tubercle bacilli through 
an eczematous patch on the face, ear, or scalp. In perhaps 95 out of 
every 100 cases of tuberculosis of the lymphatic glands the disease at- 
tacks the glands of the neck, — as the scalp, face, and mouth are parts of 
the body most frequently the seat of slight injuries and superficial 
lesions, and also most exposed to tubercular infection. The lymphatic 
glands act as filters for the microbes which enter the body through the 
lymphatic channels. The pathological conditions which are produced in 
the interior of a lymphatic gland by the presence of pathogenic micro- 
organisms are well calculated, for the time being at least, to limit the 
extension of the infection. The lymphadenitis which is produced blocks 
the lymph-spaces with the products of a specific inflammation, which, 
temporarily at least, mechanically obstructs the way for the microbes 
toward the general circulation. Primary infection of a lymphatic gland 
by the bacillus of tuberculosis in manjr instances attacks different por- 
tions of the gland from the very beginning, as a number of independent 

(505) 



506 PRINCIPLES OF SURGERY. 

centres of tissue proliferation are established around each microbe, or 
around each colony of microbes arrested on their way through the 
gland. These separate nodules soon become confluent and form a mass 
of considerable size, which soon implicates the entire parenchyma of the 
gland. Local dissemination of the bacillus of tuberculosis in the in- 
terior of the gland is accomplished by the assistance of the lymph- 
stream, as long as the microbes remain free, and through the medium 
of wandering cells as they have become attached to or have entered the 
protoplasm of the lymphoid corpuscles and leucocytes. 

Regional infection is not limited to the lymphatic glands, on the 
proximal side of the primary focus, as during the course of the disease 
we often observe that lymph-glands become involved which are not in the 
direct course of the lymph-stream. As the bacillus .of tuberculosis is 
non-motile, we can only explain its transportation in a direction opposite 
the lymph-current by its conveyance in such a direction by migrating 
amoeboid cells. As the lymph-stream is impeded or perhaps completely 
arrested by the inflammatory product which has accumulated in the 
lymph-spaces, migration of leucocytes in an opposite direction is easily 
explained. The usual course of infection along the lymphatic channels is, 
however, in the direction of the lymph-current. The course of the disease 
is almost characteristic. A lymphatic gland in the submaxillary or parotid 
region becomes enlarged, and from this centre the infection invades suc- 
cessively gland after gland, until the whole chain of lymphatics from the 
angle of the lower jaw to the clavicle has become involved. Another 
interesting feature is observed in reference to the regional diffusion of 
the tubercular process, as the course of infection usually corresponds 
to the location of the gland first affected. If the infection has involved 
primarily one of the deep glands of the neck, the glands subsequently 
invaded belong to the deep lymphatics which follow the larger blood- 
vessels of the neck. If, on the other hand, the primary depot is located 
in one of the superficial glands, the glands, which are being irrigated by 
the lymph that flows through and from the gland, become the seat of 
successive infection, showing again that regional infection usually takes 
place in the direction of the lymph-current. In extensive tuberculosis 
of the glands of the neck, the superficial and deep glands are affected at 
the same time, the infection from one set of vessels to the other being 
accomplished through the medium of communicating branches. As long 
as the infection has not extended along the entire length of the chain 
of lymphatic glands, the patient is protected against miliary tuberculosis ; 
but as soon as the. virus has passed all of the lymphatic filters it enters 
the general circulation, and diffuse miliary tuberculosis follows as an 
inevitable result. 



TUBERCULOSIS OF LYMPHATIC GLANDS. 507 

Pathological Histology and Morbid Anatomy. — As soon as a sufficient 
number of bacilli has entered the parenchyma of a lymphatic gland, a 
kaiyokinetic process is initiated which involves the parencl^ma-cells, the 
cells of the reticulum, and the endothelial cells. The proliferating tissue- 
cells produce epitheloid and giant cells, while the lymphoid elements are 
either the normal tymphoid corpuscles, which have remained unaffected 
by the inflammatory process, or leucocytes. As the number of bacilli 
present is not great, the process is a very slow one, and the inflamma- 
tory product undergoes very gradually the characteristic degenerative 
changes. The entrance of new bacilli from the infection-atrium is pre- 
vented by the obstruction in the lymph-spaces, caused Iry the accumula- 
tion within them of the products of inflammation, which arrests the 
Lymphatic circulation in the afferent vessels of the gland, through which 
primarily the bacilli entered. The bacilli found in the tubercular gland 
are, therefore, derived from the multiplication of the bacilli which origi- 
nally entered the gland from the primary infection-atrium. The cells that 
first undergo coagulation necrosis are those in the centre of each nodule, 
for reasons which have been previously mentioned. As the products of 
coagulation necrosis do not furnish the necessary nutritive material for 
the growth of the bacillus, the microbes gradually disappear in the centre 
of the nodule, while they can still be found within and between the cells in 
the surrounding granulation tissue. Cell necrosis is followed b} r caseation, 
and by this time nearly all of the bacilli have disappeared, but inoculation 
experiments with cheesy material have shown that spores remain in an 
active condition, and capable of reproducing the disease in animals. The 
numerous nodules which appear, often almost simultaneously, in the in- 
terior of the same gland become confluent, and in the course of time the 
entire parenchyma of the gland is destro} T ed, while the intact capsule of 
the organ still furnishes a wall of protection against infection for the 
surrounding tissue. A single tubercular gland is seldom larger than a 
walnut, and the large masses found in the neck and other regions are 
composed of several glands so closely packed together as to give the 
appearance of a single gland. When the capsule becomes infected, the 
same processes are initiated here as in the parenchyma of the gland ; the 
connective tissue is transformed into granulation tissue, which undergoes 
coagulation necrosis and caseation in the same manner as the fixed tissue- 
cells of the parench} r ma; and, finally, after perforation of the capsule has 
taken place, the inflammation extends to the paraglandular tissues, re- 
sulting in tubercular periadenitis. The cheesy material may dry and 
shrink and become inclosed by a capsule of dense connective tissue, 
resulting in calcification ; or it undergoes liquefaction. If secondary 
infection with pus-microbes take nlace, a not infrequent occurrence in 



508 PRINCIPLES OF SURGERY. 

tuberculosis of the glands of the neck, an acute suppurative inflammation 
takes the place of the chronic process, and almost without exception re- 
sults in a rapidly-spreading suppurative periadenitis. The connective 
tissue surrounding the gland becomes swollen and cedematous and large 
abscesses form, which, on being incised, give exit to pus which resembles 
the pus of an ordinary phlegmonous inflammation. The suppurative in- 
flammation results in extensive detachment of the cheesy glands, which 
at this time can be readily enucleated by the finger. If, however, the ab- 
scess is simply incised, and the radical operation postponed for weeks or 
months, the removal of such glands is an exceedingly difficult task, 
as the capsule of the gland will then be found intimately adherent 
to the surrounding tissues. 

Symptoms and Diagnosis. — Tuberculosis of the lymphatic glands 
occurs most frequently in persons between 15 and 30 years of age. The 
regions most frequently affected are the cervical, parotid, submaxillary, 
axillary, and inguinal. Tuberculosis of the parotid, submaxillary, and 
cervical lymphatic glands is often preceded by eczema of the scalp, ears, 
or face, or by a catarrhal or tubercular inflammation of the mucous mem- 
brane lining the nose and pharynx. It is possible that in many of these 
cases the catarrhal inflammation creates the necessary infection-atrium 
for the entrance of the bacilli into the lymphatic channels ; or, what is 
more probable, that which has been regarded as a catarrhal inflammation 
is, in reality, a mild tubercular inflammation that may disappear after 
infection of the tymphatic glands has occurred. In the region of the 
neck, the first glands affected are usually the submaxillary, or the glands 
just behind, in front, or below the external meatus. Progressive infec- 
tion is the most characteristic clinical feature of tuberculosis of the 
lymphatic glands. Regional infection, as has been stated, usually takes 
place by the extension of the disease from gland to gland, until the whole 
chain in a region has become affected. In a case far advanced, for in- 
stance, the glands first affected may be as large as a walnut; their size 
then gradually diminishes, so that those last infected may not be larger 
than a split pea. The degenerative changes are also most marked in the 
glands first affected; so that, while the primary foci show well-marked 
evidences of caseation, and caseation with liquefaction, the glands last 
infected still present a normal pinkish color. The number of glands 
affected in one region varies from one to twenty or more. If many 
glands are affected, the l^perplastic inflammation in their periphery 
usually results in their becoming matted together into a dense nodular 
mass. With the exception of the neck, it is seldom that more than one 
anatomical region is affected. In the cervical region it is not uncommon 
to find the glands on both sides affected at the same time. The infected 



TUBERCULOSIS OF LYMPHATIC GLANDS. 509 

glands increase gradually in size; they are painless and not tender on 
pressure. At first they are movable, and appear loosely attached to the 
surrounding tissues. With the appearance of periadenitis the swelling 
rapidly increases in size, and the gland becomes fixed and immovable. 
Liquefaction of the cheesy material is announced by softening and per- 
ceptible fluctuation. Secondary infection with pyogenic microbes is 
followed by phlegmonous inflammation in the capsules and in the connec- 
tive tissue surrounding the affected glands. The course of the disease, 
so far as time is concerned, is extremely variable. The extension of the 
infection and the growth of the swellings may become arrested for 
months or j^ears, when the disease may take a new start and pursue its 
typical course. I recollect the case of a woman, 45 } T ears of age, who 
had an enlarged gland the size of a hazel-nut in the upper cervical region, 
which remained stationary for twenty }^ears, when the swelling rapidly 
increased in size ; new glands became infected, and, when the glands were 
removed by operation, it was seen that the first gland was composed of 
a thickened capsule, distended to its utmost by inspissated cheesy ma- 
terial. The capsule showed evidences of recent tubercular inflammation, 
and small foci of caseation were detected in the glands that had recently 
become infected. When a true suppuration takes place in a tubercular 
lymphatic gland, it does so in consequence of a secondary infection with 
pyogenic microorganisms. A spontaneous and permanent cure is not 
infrequently effected by the substitution of an acute suppurative process 
in place of the primary specific chronic inflammation, which destroys the 
entire soil of the bacillus tuberculosis and, at the same time, effects com- 
plete elimination of the bacilli through the discharges of the abscess. 
While tuberculosis of the Pymphatic glands often stands in a direct causa- 
tive relationship to and precedes general, diffuse, and pulmonary tuber- 
culosis, it is seldom observed as a secondary affection in the course of 
pulmonary tuberculosis. I have observed one case of tuberculosis of 
the lungs with secondary infection of the lymphatic glands. The patient 
was a woman, 50 years of age, who had suffered for two years from well- 
marked t3*pical tuberculosis of the lungs, when the glands on both sides 
of the neck became infected, and continued to increase in number and in 
size until she died, six months later. Frankel reports an interesting case 
in which lymphatic and pulmonary tuberculosis developed almost simul- 
taneously. The patient was a woman, 51 years of age, who had given 
birth to two children, their father being the subject of advanced tuber- 
culosis, and both of whom died of tuberculosis. She had been in perfect 
health until her 49th year, when she was attacked simultaneously with 
pulmonary and glandular tuberculosis, from the continued elt'ects of 
which she died in a few months. In exceptional cases glandular tuber- 



510 PRINCIPLES OF SURGERY. 

culosis pursues an acute course. Delafield reports an exceedingly inter- 
esting case of this kind. The disease commenced with enlargement of 
one of the cervical glands near the angle of the lower jaw, with a tem- 
perature of 40° C. (104° F.), and rapid extension to the proximal glands 
as far as the clavicle. Symptoms of pulmonary complication were not 
present. Rapid emaciation and marked anaemia supervened, followed 
after six weeks by swelling of axillaiy and inguinal glands. Ophthalmic 
examination revealed the same conditions of retina and papilla as in 
leucaemia or Bright 's disease. A few days after the beginning of the 
disease profuse diarrhoea and reduction to nearly normal temperature 
occurred. The diagnosis was between malignant lymphoma and tuber- 
cular adenitis. Durino- the further course of the disease bronchial 
breathing in both lungs appeared. Heart, liver, and spleen appeared to 
be normal. Urine normal, but increase of temperature and respirations 
took place during this time. Death occurred in less than five months. 
At the autopsy the lungs were found congested and (edematous, with, red 
hepatization of the lower lobes and a few miliary tubercles. The spleen 
contained many miliary tubercles the size of the head of a pin, and most 
of them in a state of cheesy degeneration. The mesenteric glands were 
much enlarged, and a few of them in a condition of cheesy degeneration 
and calcification. In the chees}^ matter bacilli were found. All the cer- 
vical glands were affected with softening and cheesy degeneration in the 
centre. The calcification of mesenteric glands pointed to an earlier 
affection. The disease remained latent and recurred in the same glands, 
and, later, extended to the cervical glands. This case resembles the cases 
described by Hilton-Fagge and Pye-Smith. 

In reference to the dissemination in cases of acute miliary tuber- 
culosis, Weigert has pointed out that in some cases the bacilli are con- 
ve}^ed through the lymphatic S}^stem successively until they reach the 
general circulation, while in others, and by far the greater number, 
generalization of the tuberculous process takes place more directly by 
the entrance of tubercular products through a vein, — an occurrence which 
is followed at once by rapid and extensive diffusion Irv embolic processes ; 
when the bacilli have reached the systemic circulation, the intensity of 
symptoms and subsequent course of the disease depend on the number 
of bacilli which the blood contains. As regards the frequency of 
secondary infection of the lungs in cases of glandular tuberculosis, 
Frankel found it present in only 18 out of 148 cases. In making a 
differential diagnosis it becomes necessaiy to distinguish tubercular 
adenitis from simple adenitis, suppurative adenitis, S3 r philitic adenitis, 
carcinoma, tymphoma, lympho-sarcoma, and pseudo-leucaemia. 

Simple adenitis is the result of the entrance into the lymphatic 



TUBERCULOSIS OF LYMPHATIC GLANDS. 511 

circulation of noxse that neither produce suppuration nor the formation 
of new tissue. A number of glands corresponding to the direction of 
the lymph-current from the infection-atrium, through which the irritant 
gained entrance, enlarge, but the inflammatory swelling subsides shortly 
after the cessation of the primary cause, with perfect restoration of the 
structure and function of the affected glands. Suppurative adenitis is an 
acute affection which terminates in the formation of pus in a few days. 
Syphilitic adenitis developing in the course of a primary syphilitic sore 
only attacks the glands contaminated with lymph coming from the infected 
area. The adenitis which accompanies secondary and tertiary syphilis 
is not limited to a single region ; nearly all of the external lymphatic 
glands are more or less enlarged, but especially those in the occipital 
and cubital regions. Carcinoma never occurs as a primary lesion in the 
lymphatic glands, and when regional infection has occurred it is not 
difficult to locate the primary tumor. Lymphoma is a benign tumor of 
the lymphatic glands, and as such is always met with as a single tumor. 
Lympho-sarcoma represents the primary malignant tumor of the lym- 
phatic glands, and gives rise to regional and general infection, the infec- 
tion in these respects resembling the clinical tendencies of tubercular 
adenitis. Lrympho-sarcoma, however, is a tumor, not an inflammatory 
swelling, and, consequently, the tissues of which it is composed do not 
undergo degeneration and necrosis at such an early stage, and the rapid 
tissue increase leads to the formation of large tumors, while tubercular 
glands the size of an almond contain cheesy material. The unlimited 
growth which characterizes sarcoma is checked in the tubercular glands 
by necrosis of the cells which compose the swelling. In pseudo-leucaemia 
the fixed tissue-cells of the parencl^ma of the glands proliferate by 
being acted upon by a microbe as yet unknown ; but this microbe, unlike 
the bacillus of tuberculosis, is diffused more extensively through the 
lymphatic sj^stem, involving one region after another until, after the 
disease has been once well developed, almost every lymphatic gland in 
the body has become infected. The supposed microbe of pseudo- 
leucaemia possesses the property of producing new tissue by its action 
upon the fixed cells, but the new product does not undergo caseation. 
As the last and infallible diagnostic measures, must be mentioned the 
search for the bacillus of tuberculosis by the use of the microscope and 
inoculation experiments. 

Prognosis. — A tubercular lymphatic gland is alwa} r s a source of 
danger. Even if the disease becomes latent, a recurrence ma}' take place 
at any time, and lead to rapid regional and general infection, or general 
infection may take place directly from an old cheesy focus b} r the 
entrance of bacilli or their spores into a vein. The prognosis is very 



512 PRINCIPLES OF SURGERY. 

grave if the patient is anaemic, and the glands on both sides of the neck 
are affected at the same time. Frankel estimates the average duration 
of the disease from three to four years. In the cases which he collected 
the shortest time was two months and the longest thirty years. Sooner 
or later, pulmonary or diffuse general tuberculosis is almost sure to take 
place. A spontaneous cure is possible if secondary infection occur in 
cases where onty a few of the glands have become infected, and suppu- 
ration results in the elimination of all the infected tissue. Suppuration 
only hastens a fatal termination if many glands are affected. 

Treatment. — As primary lymphatic tuberculosis, in most instances, 
signifies the entrance of bacilli through a loss of continuity of the skin 
or a mucous membrane, or through the socket of a carious tooth, locali- 
zation occurring in one of the nearest glands to the portio invasionis, it 
must be regarded primarily as a local process amenable to timely surgi- 
cal treatment. The capsule of the lymphatic glands constitutes a very 
efficient barrier against infection of the paraglandular tissue for a long 
time, and perforation of the capsule can only take place after the disease 
has made considerable progress, and has been followed by extensive 
caseation and especially by suppuration. Early operative interference 
is as necessary in the treatment of tubercular adenitis as in the treatment 
of malignant tumors, and holds out more encouragement, so far as a per- 
manent cure is concerned. By a thorough removal of the primary foci 
of infection, successive infection of proximal glands and general miliary 
tuberculosis are prevented almost to a certainty if the operation is per- 
formed before the disease has extended beyond the capsule of the glands. 
If the operation is done at such a favorable time it is not attended by 
any great difficulties, as the glands can be readily enucleated, and, as 
suppuration has not taken place, the wound usually heals by primary 
intention. If, however, the tubercular inflammation has involved many 
glands, and has extended to the connective tissue surrounding them, the 
operation becomes one of the most formidable in surgery, on account of 
the close proximity of important vessels that are often imbedded in the 
mass. Under such circumstances complete removal is frequently impos- 
sible and early local recidivation is inevitable, owing to imperfect re- 
moval of the primary microbic cause. Traumatic dissemination is very 
likely to follow all imperfect operations in which portions of glands or 
infected capsules are left behind, as the operation wounds are inoculated 
with bacilli liberated during the operation. I have seen in a number of 
such cases, as early as a week after the operation, the entire surface of 
the wound covered by a thick layer of granulation tissue, which showed 
all the histological evidences and possessed all the bacteriological prop- 
erties of tubercular tissue. As a testimony in favor of the operative 



TUBERCULOSIS OF LYMPHATIC GLANDS. 513 

treatment of tubercular adenitis, I will quote from the paper of Schuell, 
who collected 56 cases of tuberculosis of the cervical glands that were 
treated by extirpation in the clinic at Bonn. In 37 of these cases he was 
able to learn the ultimate result. In 57 per cent, the operation was fol- 
lowed by complete recovery, in 27 per cent, the disease returned at the 
site of operation, and in 4 cases death resulted from pulmonary tubercu- 
losis. The largest number of cases were patients between 10 and 20 
years of age. 

Frankel reports 128 cases operated upon by Billroth, some of the 
operations being quite serious ; in 16 cases the internal jugular vein had 
to be tied. In 91 of the operations the wound healed by primary union, 
and in 25 the healing was retarded by suppuration. Erysipelas compli- 
cated the result five times. In one of these cases a large part of the tuber- 
cular mass was left, and it was noticed that the erysipelas had no effect 
on the tubercular process. Only in 49 of the cases operated on could 
the final result be obtained. Taking three and a half 3 T ears as the time 
when the patient could be considered exempt from a recurrence of the 
disease, it was ascertained that in 24 per cent, no relapse followed the 
operation, a local relapse was observed in 14 per cent., and re-appearance 
of the disease distant from the seat of operation in 4 per cent. The 
results of operation for tuberculosis of the lymphatic glands have shown 
the necessity of early operating, as delay renders the operation more 
difficult, on account of the progressive regional dissemination of the dis- 
ease and the occurrence of pathological changes within and around the 
affected glands, which render their complete removal more difficult ; 
while at the same time the danger of general infection increases with 
the local extension of the disease. If the glands have suppurated, or if 
the capsule has become perforated and tubercular periadenitis or sup- 
purative periadenitis has taken place, and many glands are simultane- 
ously affected, it may not be advisable to resort to excision, as when 
extensive connective-tissue infiltration is present it would be almost 
impossible to remove all of the infected tissues. 

In such cases free incisions should be made, and the tubercular 
product be removed with a Volkmann spoon. The proximal glands 
which have not undergone such extensive secondary pathological changes 
can be excised. The scraped surface is freety iodoformized and the 
wounds are sutured and drained. In removing the glands of the neck it 
is always important to expose the infected area by a large incision. The 
operator should not only feel, but see, every gland he removes. Accidents 
are more liable to happen by removing the glands through a small than 
a large incision. As in cases of secondary carcinoma of the l\ T mphatic 
glands the extent of the disease is only ascertained after incision, so in 



514 PRINCIPLES OF SURGERY. 

glandular tuberculosis the extent of the area of infection can only be 
ascertained after the external incision is made. Whole chains of small 
glands which could not be felt through the skin are then exposed. In 
tuberculosis of the glands of the neck the region between the mastoid 
process and the angle of the lower jaw is almost always the primary seat 
of infection. From here either the chain of glands behind the sterno- 
cleido-mastoid muscle or the deep glands which follow the sheath of the 
large vessels of the neck are affected, or the superficial and deep lym- 
phatics are affected simultaneous^. It has been my custom to expose 
the glands occupying the upper region of the neck by a transverse in- 
cision, extending from the tip of the mastoid process of the temporal 
bone to the lower angle of the jaw, and from there along the lower border 
of the bone, as far as the disease extends in the submaxillary region. 
This incision is joined by another, extending from the angle of the lower 
jaw either along the anterior border of the sterno-cleido-mastoid muscle 
as far as its sternal insertion, if the deep glands are to be removed, or, if 
the posterior superficial set of glands are affected, it is carried in a down- 
ward and backward direction, following the chain of enlarged glands. If 
the latter incision is selected, the external jugular vein is divided between 
two ligatures. The platysma myoides muscle is divided throughout the 
whole length of the incision before an attempt is made to remove any of 
the glands. The surgeon should aim to remove, as nearly as he can, all 
of the infected glands in one disconnected string. In many cases one or 
two tubercular glands will be found imbedded in the lower portion of 
the parotid gland, and veiy frequently also in the submaxillary salivary 
gland. If the tubercular glands, with their capsules, can be enucleated, 
this should be done ; but if this is impossible, it is better to remove the 
lower portion of the parotid with them in preference to leaving any 
infected tissue behind. Under the same circumstances I prefer to ex- 
tirpate the submaxillary gland in toto. If the deep glands of the neck 
must be removed, it is absolutely necessary to divide the sterno-cleido- 
mastoid muscle near its centre, and then reflect both ends nearly as far 
as the origin and insertion of the muscle, which freely exposes not only 
the affected glands, but also the important structures of the neck, which 
it is important to avoid in the dissection. The dissection must always 
be made with the greatest care, and in the vicinity of the large vessels 
every structure must be identified before it is separated. The finger and 
blunt-pointed, curved scissors are the most important instruments in 
making the deep dissection. The internal jugular vein should be seen 
before any of the deep glands are removed, for if this structure is seen 
it can be carefully followed the whole length of the neck without 
wounding it unintentionally. If the internal jugular vein is imbedded 



TUBERCULOSIS OF LYMPHATIC GLANDS. 



515 



among the enlarged glands, and cannot be isolated without great danger 
of injuring it, it is better to resect it between two ligatures than to run 
the risk of wounding it accidentally. The chain of enlarged glands is 
followed as far as possible, as it is much better to remove a few healthy 
lymphatic glands than to leave minute, almost invisible foci of the dis- 
ease. After all the infected glands have been removed the continuity 
of the divided muscle is restored by / suturing. At least six catgut 
sutures are necessary to join the thick ends accurately. I have usually 
succeeded in removing all the glands after divison of this muscle with- 
out dividing the spinal accessory nerve, but, should this be necessary, 
the divided ends are joined by suturing before the muscle is united. 
Drainage in the submaxillary region and at the most dependent point 
of the wound in the neck must always be established. The platysma 
muscle should be united with buried 
sutures before the skin is sutured. 
I have recently, except in cases of 
very limited tuberculosis of the cer- 
vical glands, abandoned the straight 
incision, which is followed so often 
by a disfiguring scar, and have 
substituted for it an incision which 
resembles the shape of the letter S, 
as here illustrated. This incision 
affords free access to the deep tissues 
of the neck and the entire chain or 
chains of tubercular glands, and the 
'resulting scar never appears in the 
form of an elevated, disfiguring ridge. 
Wounds of the neck, on account 
of the irregular outlines of the neck, shoulder, and chest, require a very 
copious antiseptic dressing to effectually exclude the entrance of patho- 
genic microorganisms after the operation. The dressing should be kept 
in place by a few turns of the plaster-of-Paris bandage, which also keeps 
the head in proper position during the time required in the healing of the 
large wound. The sutured muscle must be kept in a relaxed position 
until firm union has taken place between the sutured ends, which usually 
requires from two to three weeks. On the second or third day the 
dressing is changed, the drains are removed, and, if the wound has 
remained aseptic, the second dressing can be allowed to remain for ten 
days or two weeks, when it is changed, and the superficial stitches are 
removed. If all of the diseased tissues have been removed, and the 
wound has remained aseptic, the healing process will be found nearly 
completed at this time. 




Fig. 155. — S-shaped Incision in the 
Operation for the Removal of 
Tubercular Glands of the Neck 



516 PRINCIPLES OF SURGERY. 

Local recurrence of the disease should only stimulate the surgeon 
to continue the active warfare, and glands are removed as soon as they 
can be felt. I have repeatedly performed, on the same patients, three and 
four operations in as many years, and had the satisfaction of finally 
eradicating the disease completely. Parenchymatous injections of car- 
bolic acid, so strongly recommended by Hueter in the treatment of 
tubercular glands, have little or no effect in either arresting further 
development of the disease in the affected glands or in preventing 
further regional infection. I have seen, in cases treated by this method, 
glands finally destroyed by suppuration caused by the punctures ; but 
the bacilli remained in the cicatricial tissue, as was evident by the 
oedematous, congested scar, and from here additional glands became 
infected. 

Grenzmer advised ignipuncture in the treatment of tubercular 
glands, and claims for this method excellent results. This treatment is 
applicable only in cases where a few of the more superficial glands are 
affected, and where patients positively refuse to submit to a more radi- 
cal procedure. It is absolutely contra-indicated when man}' glands are 
affected, as in cases where the glands are affected they have undergone 
extensive secondary pathological changes. The general treatment of 
tuberculosis of the lymphatic glands is the same as in the other forms of 
local tuberculosis. I have seen the best effects from the administration 
of guaiacol, arsenic, and iron, followed or alternated hy codliver-oil. All 
external applications to bring about resolution are worse than useless. 

TUBERCULOSIS OF PERITONEUM. 

Tubercular peritonitis occurs as one of the lesions of acute general 
tuberculosis, with chronic pulmonaiy phthisis, with tubercular inflamma- 
tion of the geni to-urinary tract, and as a local inflammation. As a sur- 
gical lesion only the local form will be considered here. 

Bacteriological Remarks. — The susceptibility of the peritoneum to 
tubercular infection has been well established b} r numerous inoculation 
experiments. The peritoneum can, under favorable conditions, dispose 
of a large dose of a pure culture of pus-microbes, but the implantation 
of a minute fragment of tubercular tissue in animals susceptible to 
tuberculosis is almost certain to be followed b} T genuine local and general 
tuberculosis. For the surgeon, only those forms of peritoneal tubercu- 
losis have interest which are either caused by an extension of an adja- 
cent tubercular process to the peritoneum or from primary localization 
of the bacillus within or upon this membrane. The prevalence of the 
affection in the female sex, among the cases which have been reported, 
points to the Fallopian tubes as a frequent primary seat of infection, 



TUBERCULOSIS OF PERITONEUM. 517 

with secondary invasion of the peritoneum from this source. Although 
the genital organs in the male are more frequently the seat of tubercu- 
losis than in the female, so far only a few cases of peritoneal tuberculosis 
in males have been reported, — by Kiimmell, Lindfors, and others. 
Tuberculosis of the peritoneum, by extension from a tubercular focus 
in the genital organ, can only mean an infection by contact, the bacillus 
of tuberculosis transferred from the primary seat of infection, and 
localization by implantation upon the peritoneal surface. Implantation 
experiments in animals furnish a good illustration of the manner in 
which the process becomes diffuse. At the point of implantation a 
granulation mass forms around the graft, and from here innumerable 
tubercle nodules take their starting point, forming ever3 7 where new 
centres of infection. The movements of the abdominal walls during 
respiration and the peristaltic action of the intestines are potent factors 
concerned in the local dissemination of the tubercular infection. Ana- 
tomically, the peritoneum is so closely allied to the lymphatic glands 
that we have every reason to believe that primary tuberculosis can occur 
in this structure as well as in the lymphatic glands. In primary tuber- 
culosis of the peritoneum infection takes place in the same manner as in 
intact joints, by floating bacilli becoming arrested in the capillary ves- 
sels of the membrane, where the primary nodule forms, from which, 
again, as from a graft, local dissemination takes place. These cases are, 
in the true sense of the word, not cases of primary tuberculosis, as the 
peritoneal affection is only a local expression of an antecedent infection. 
As the peritoneum is endowed with absorptive capacities of a high 
degree and is in direct communication with the lymphatic s} T stem, we 
would naturally expect that tuberculosis of this structure would lead to 
early general dissemination. But in peritonenl tuberculosis we observe 
the same tendency to limitation of the infective process as in joints, by 
the formation of an impenetrable wall of connective tissue, which 
imparts so often to this form of peritonitis its circumscribed character. 

Clinical Studies. — Kiimmell looks upon peritoneal tuberculosis as a 
purely local affection, amenable to surgical treatment in the same sense 
and to the same extent as a tuberculosis of joints. That some of these 
cases can be permanently cured by local treatment is well shown by a 
case treated by, Sir Spencer Wells twenty-six years ago by abdominal 
section, the patient having remained up to this time in perfect health. 
In a recent paper on this subject Fehling reports 4 cases of his own, 
and gives an account of all the operations which had been done up to 
that time, — 21 in number. Of this number 15 recovered, and the patients 
are known to have been well from one year to twenty -three } T ears, and 
in a number of cases their condition was learned four to five years after 



518 PRINCIPLES OF SURGERY. 

the operation. Six of the patients died, — 2 of sepsis, 1 of pyaemia 
several months after the operation, and 3 from the continuance of the 
disease for which the operation was performed. In 5 of the cases ascites 
attended the tuberculosis ; in 3 the swelling was not due to effusion, 
but to adhesions between intestinal loops that were covered with miliary 
tubercles. 

Of 54 cases of laparotomy for peritoneal tuberculosis, collected by 
Trzebiclrv, 4 died from the immediate consequences of the operation, 
while in a fifth death occurred after the operation from acute miliary 
tuberculosis, though the fluid had not re-accumulated. One case died in 
four months from general tuberculosis without the peritonitis disappear- 
ing ; cures resulted in 40 cases, though here and there evidence of pul- 
monary tuberculosis was reported. The majorit}' of cases were females, 
which may find its explanation in the fact that most were operated upon 
under error in the diagnosis of ovarian cyst. The most recent and com- 
prehensive work on tuberculosis of the peritoneum, which has recently 
appeared from the pen of Vierordt (" Ueber die Tuberculose der serosen 
Haute," in Zeitschrift f. klin. Medicin., Bd. xiii, Heft 2), should be con- 
sulted by those who wish to secure for reference an exhaustive treatise 
on this subject. The statistics are yet too meagre, the correctness of 
diagnosis not entirely above doubt, and the period of observation after 
operation not long enough; but, in view of the results, there is no longer 
an} 7 justification for expectant treatment. Even though in some cases 
recovery was not permanent, the fluid did not re-accumulate, and the 
patients were relieved of their distress. Spontaneous recovery from 
tubercular peritonitis is exceptional, and operative interference is indi- 
cated the more, as it would seem that, in many cases, tuberculosis of the 
peritoneum is a primary affection and the source of general infection. 
As all other therapeutic measures are of no permanent value in such 
cases, and laparotomy done under antiseptic precautions may be con- 
sidered almost free from danger, the operation is certainly strongly 
indicated. 

Pathology and Morbid Anatomy. — The effect of the bacillus of tuber- 
culosis on the peritoneum is not uniform, and the conditions found in 
peritoneal tuberculosis are variable. Lindfors, in a clinical and patho- 
logical study, based on 109 recorded cases of peritoneal tuberculosis, 
divides the cases into seven classes. He states that the acute variety 
may assume the form of circumscribed, general, or suppurative perito- 
nitis ; in the chronic form there may be a free or encysted effusion, there 
may be simple adhesions, or the intestines may be so adherent as to 
cause intestinal obstruction. Lindfors thinks that the presence of acute 
or chronic pleurisy has an important bearing on the diagnosis of tuber- 



TUBERCULOSIS OF PERITONEUM. 519 

cular peritonitis. He is strongly in favor of laparotomy and the free use 
of iodoform within the peritoneal cavity. The conditions found in local 
tubercular peritonitis, in cases subjected to operative treatment and in 
examinations made in the post-mortem rooms, are such that all cases of 
this kind can be conveniently classified in three principal groups upon a 
pathological basis : — 

1. Tubercular Ascites. — The peritoneum is thickened, liypersemic, 
and studded with masses of tubercle tissue in the form of miliary 
nodules. The omentum is usually similarly affected. If the effusion is 
general, occupying the whole peritoneal cavity, the adhesions are few 
and slight. If the fluid is encapsulated the walls of the cavity are 
formed b}^ intestinal loops, which are adherent among themselves and 
to the surrounding structures. The circumscribed form usually takes 
its origin from the floor of the pelvis, and often gives rise to a swelling 
which simulates an ovarian cyst to perfection. The fluid contained in 
the peritoneal cavhYy in the diffuse form, and in the confined space in the 
circumscribed variety, is either a clear, transparent serum, or serum in 
which small flocculi are suspended, or the fluid has become slightly 
turbid from the admixture of the products of retrograde tissue metamor- 
phosis. The visceral peritoneum of the organs exposed to infection is 
in the same condition as the parietal peritoneum. Coagulation necrosis 
and caseation of the nodules appear to be retarded for a much longer 
time than in cases of glandular tuberculosis. The amount of fluid may 
vary from a teacupful in the circumscribed to 4 or 6 gallons in diffuse 
tubercular ascites. Secondary infection is found most frequently in the 
spleen, pleurae, and lymphatic glands. 

2. Fibrinoplastic Peritonitis. — In this form of tubercular peritonitis 
no fluid is found in the peritoneal cavity. The bacillus of tuberculosis 
produces a copious inflammatory product, and the peritoneal surfaces, 
which are studded with miliary tubercles, are covered by a thick layer 
of gelatinous fibrin, which cements together all the adjacent serous 
surfaces, so that the whole abdominal cavity appears to be filled with a 
large, boggy mass, composed of all the viscera adherent to each other, 
and with the interspaces between them filled with fibrin. The inflam- 
matory product in these cases is rich in fibrin-producing substances, 
while the liquid transudation is either scanty or is absorbed as soon as 
it is poured out. 

3. Adhesive Peritonitis. — In this variety of tubercular peritonitis 
the bacillus of tuberculosis exerts its pathogenic properties more on the 
fixed tissue-cells than the blood-vessels. The primary inflammatory 
exudation is slight, but the endothelial cells proliferate new tissue, which 
undergoes cicatrization, giving rise to firm and extensive adhesions. The 



520 PRINCIPLES OF SURGERY. 

plastic peritonitis may be so extensive as to cause intestinal obstruction 
from perfect immobilization of a large portion of the intestinal tract. 
In this, as well as in the foregoing form of tubercular peritonitis, ulcera- 
tion of the intestine may take place, resulting in the formation of a bi- 
mucous, internal fistula if the openings in two adjacent loops correspond, 
or the formation of a faecal abscess with a subsequent faecal fistula. 

Symptoms and Diagnosis. — As tubercular peritonitis without effusion 
is not amenable to successful surgical treatment by laparotomy, nothing 
will be mentioned in reference to the diagnosis and treatment of the 
fibrinoplastic and adhesive varieties. Tubercular ascites is a chronic 
affection, especially when it occurs in the circumscribed form. Pain and 
tenderness are not prominent or even constant symptoms. The general 
health is at first but little impaired. Fever is slight or entirely absent. 
If the effusion is general, it comes on slowly, almost insidiously, as in 
ascites from other causes. From the absence of adhesions the fluid 
changes its location according to the position of the patient. If the 
patient is placed in the dorsal, recumbent position, the lumbar regions 
are dull on percussion ; if placed on the side the upper lumbar region is 
tympanitic, while the area of dullness on the opposite side is increased. 
In circumscribed tubercular peritonitis with encapsulation of the fluid, 
the swelling appears first either in the hypogastric or one of the iliac 
regions. The area of dullness does not change by placing the patient in 
different positions. In free ascites tuberculosis of the peritoneum should 
be suspected, if the ordinary causes of ascites, cirrhosis of the liver, 
valvular disease of the heart, and the presence of an intra-abdominal 
malignant tumor can be excluded. Circumscribed tubercular ascites 
might be mistaken for ovarian cyst, pregnancy, pyo- or hydro- salpinx, 
pyo- or hydro- nephrosis, cyst of pancreas, enlarged gall-bladder, and 
pelvic abscess. Fluctuation is a symptom common to all of these 
conditions, and a differential diagnosis can only be made by a careful 
stmty of the clinical history and b}^ a thorough examination. Pregnancy 
can usually be excluded by ascertaining the size of the uterus and by 
the presence or absence of the usual signs of gestation. A pyo- or hydro- 
salpinx can generally be recognized by bimanual exploration, especially 
if the examination is made, as it should be, under the influence of an 
anaesthetic. A pelvic abscess is alwa}^s preceded by an acute suppura- 
tive para- or peri- metritis, attended by severe symptoms which are absent 
in tubercular peritonitis. Cystic affections of the gall-bladder, pancreas, 
and kidney begin in the upper part of the abdominal cavity, while the 
reverse is usually the case in tubercular ascites. 

The greatest difficulty presents itself in differentiating between a 
circumscribed tubercular ascites and an ovarian cyst. So close is the 



TUBERCULOSIS OF PERITONEUM. 521 

clinical resemblance of these two affections that a positive diagnosis is 
almost impossible without the aid of an exploratory laparotomy, and, as 
both affections can only be treated successfully by abdominal section, it is 
sufficient for all practical purposes to narrow the diagnosis down to one 
of these and reserve a positive diagnosis until the abdomen is opened. 

Treatment. — The surgical treatment of tubercular peritonitis with 
effusion by laparotomy has yielded sufficiently satisfactory results to 
make it an established procedure in such cases in the future. A 
spontaneous cure is the exception ; death from local extension of 
the disease and from general infection the rule. A case came under 
my observation a few years ago where I have every reason to believe 
that tubercular ascites disappeared spontaneously. The patient was 
a woman, 40 years of age, with a marked hereditary tendency^ to tuber- 
culosis, several sisters having died of pulmonary tuberculosis. She 
was the mother of several children, the youngest being 6 years old. 
She was brought to me bj T her family physician with the diagnosis 
of ovarian cyst. She had been ailing for two years. When I ex- 
amined her the swelling was as large as a child's head, occupying 
the hypogastric and left iliac region. Fluctuation distinct ; no pain 
and but little tenderness on pressure ; menstruation regular. General 
health only slightly impaired. After a careful examination I coincided 
with the diagnosis, and advised an early operation. Soon after this time 
the swelling began to diminish in size and disappeared completely in the 
course of a year, but the general health, instead of improving, began to 
fail. After the disappearance of the swelling she began to suffer from a 
deep-seated pain at a point corresponding to the cartilage of the eighth 
rib on the left side, and in the course of a few months a fluctuating 
swelling appeared under the costal arch at that point. Tuberculosis of 
the ribs was suspected, but at the time of operation an encapsulated 
tubercular abscess was found in the abdominal cavity, to the left of the 
great curvature of the stomach and above the splenic flexure of the colon. 
A large quantity of liquefied, caseous material was evacuated. The wall 
of the abscess was lined with a thick layer of granulation tissue, which 
was thoroughly removed with a sharp spoon, and after irrigation the 
cavity was carefully dried and packed with iodoform gauze. The wound 
healed by primary intention, and the entire cavity closed in the course 
of four weeks without a drop of pus. The woman has since greatly im- 
proved in health and is completely relieved of her pain. There can 
hardly be a question that the accumulation of fluid which was mistaken 
for an ovarian cyst was a limited ascites, caused by a circumscribed 
tubercular peritonitis, and that the infection in the upper portion of the 
abdominal cavity resulted from this, the primary depot. It is not at all 



522 PRINCIPLES OF SURGERY. 

improbable that, had an operation been performed at the time it was ad- 
vised, this extension of the infection might have been prevented. The 
results obtainable by laparotomy in the two different forms of tubercular 
ascites are well shown by two cases which occurred in my own practice. 
The first patient was a girl, IT years old, without a tubercular his- 
tory. She had always been in good health until about a year before she 
came under my observation, when she commenced to suffer from pain in 
the left iliac region, and soon after a perceptible swelling appeared in 
that locality, which gradually increased in size until the time I saw her, 
when it reached above the umbilicus and beyond the median line. Has 
never menstruated. Patient was anaemic and somewhat emaciated, but 
was never confined to bed. Examination revealed no disease in any of 
the important organs. Diagnosis of ovarian cyst had been made by 
several physicians. The abdomen was opened by a median incision, and 
a large quantity of clear, straw-colored serum escaped as soon as the 
peritoneum was incised. The parietal peritoneum, as well as the in- 
testines, which formed a part of the wall of the cavity, were studded with 
innumerable nodules the size of a millet-seed. These nodules were largest 
and most numerous in the region of the left Fallopian tube, which, how- 
ever, was normal in size. The cavity was dried and freely dusted with 
iodoform, and a Keith glass drain inserted as far as the floor of the space 
of Douglas. A large quantity of serum was removed from the tube for 
the first few days, when it became more and more scanty, so that the 
glass tube could be removed at the end of the second week. Through a 
small fistulous tract serum continued to escape for six weeks, when the 
fistula closed. The patient gained fifteen pounds in weight, and a year 
after the operation was in perfect health, with no signs of a local return. 
That the peritonitis in this case was tubercular was demonstrated by an 
inoculation experiment. A nodule was removed from the peritoneum and 
implanted into the peritoneal cavity of a guinea-pig, with a positive result. 
The second case was a woman, 42 years of age, without any history of 
tuberculosis in her family. She is the mother of a large family, the 
youngest child being 5 years of age. Her abdomen began to enlarge four 
months before she came under my care. Pain not severe, but gradual 
loss of flesh and strength. As no local cause for the ascites could be 
found, the abdomen was opened in the median line and at least two pail- 
fuls of clear serum escaped. The intestines and parietal peritoneum 
presented an exceedingly vascular appearance and were studded with 
minute miliary nodules. These nodules, again, were largest in the pelvis, 
but both tubes were found in a normal condition. The same course was 
pursued as in the first case, and drainage was kept up for two weeks, 
when the flow of serum was so scanty that it was deemed advisable to 



TUBERCULOSIS OF PERITONEUM. 523 

remove the tube. The wound healed completely in a few days, and the 
patient left the hospital greatly relieved. The fluid, however, accumu- 
lated so rapidly that in two weeks she had to be tapped, and from this 
time on the patient could not leave her bed. The tapping had to be re- 
peated every two weeks. Symptoms of pulmonary phthisis developed 
soon after she left the hospital, and death from general miliary tubercu- 
losis occurred in less than three months after the operation. The 
danger of re-accumulation of fluid and general infection is much greater 
in diffuse tubercular peritonitis than in the circumscribed form, as in the 
latter the area of infection is more limited, and general infection is less 
likely to occur on account of the presence of a wall of plastic material 
which surrounds the tubercular field. In operating for circumscribed 
tubercular ascites it is very important to exercise great care in opening 
the abdominal cavity, as a loop of adherent intestine may be found at the 
point where the incision is made. The peritoneum must be recognized 
and carefully divided in order to prevent wounding of the bowel, should 
such a condition be met with. Iodoformization of the cavity is one of the 
important indications of treatment. Drainage must be maintained until 
accumulation of serum in the tube has ceased. Uniform equable com- 
pression of the abdomen with strips of adhesive plaster or a well-fitting 
bandage should be kept up throughout the entire after-treatment. In 
cases where a well-defined local tubercular focus is found, which we have 
reason to regard as the cause of the peritonitis, this should be removed 
or rendered harmless by appropriate treatment. A tubercular Fallopian 
tube should be removed if this can be done. Other caseous foci are re- 
moved with a sharp spoon, or they can be destroyed or rendered harmless 
by ignipuncture and thorough iodoformization. 

Lauenstein attributes the curative effect of laparotomy in cases of 
tubercular ascites to the admission of atmospheric air, and, acting upon 
this theory, inflation of the abdominal cavity after tapping has been 
resorted to as a therapeutic agent, but the results following this treat- 
ment have not been encouraging. In two cases of limited tubercular 
ascites the writer has secured excellent results from tapping followed 
by injection of 4 drachms of a 10-per-cent. emulsion of iodoform in 
gtycerin. Both cases resulted, apparently, in a permanent cure. Both 
patients were placed at the same time upon the internal use of guaiacol. 



CHAPTER XXI. 

Tuberculosis of Bones and Joints, 
tuberculosis of bone. 

Next to the lungs and lymphatic glands the bones are most fre- 
quentty the sent of tubercular infection. Tuberculosis of the bones is 
an exceedingly frequent affection in children and young adults. Its 
favorite location is in the epiphyseal extremities of the long bones, 
although it is also quite frequently met with in the short bones of the 
carpus and tarsus and some of the flat and irregular bones, as the ribs, 
scapula, ileum, and vertebrae. 

Embolic Infection the Cause of Osseous Tuberculosis. — Practically, 
direct tubercular infection does not occur, and when the disease has 
made its appearance it is only an evidence of the existence of a tuber- 
cular focus in some other organ. We observe clinically, what Mueller 
has demonstrated experimentally, that, when the bacilli of tuberculosis 
are present in the blood-current, very often localization takes place near 
the epiphyseal cartilage in young persons by the microbes becoming 
arrested in one of the terminal branches of an artery, the lumen of 
which becomes obliterated by the presence of a minute embolus of 
granulation tissue containing bacilli; or the lumen of the vessel is 
gradually diminished by the formation of a mural thrombus, which 
forms around bacilli implanted upon the vessel-wall, and the lumen 
of the vessel is finally completely obstructed by the growth of the 
thrombus. 

The new vessels in the vicinity of the centres of growth in the bones 
of young persons, on account of their imperfect structure and irregular 
contour, furnish the most favorable conditions for the arrest of floating 
granular matter and the localization of pathogenic microbes. The pre- 
disposing anatomical element goes far to explain the frequency with 
which we meet w r ith tubercular foci in the epi pity seal extremities of the 
long bones. 

The following table, prepared by Schmallfuss, gives a good idea 
of the relative frequency with which different bones are affected with 
tubercular lesions : — 

(524) 



TUBERCULOSIS OF BONE. 



525 



Billroth. 


Jaffe. 


Per Cent. 


SCHMALIiFUSS. 


Per Cent. 


Vertebra. 


Vertebra. 


26 


Knee. 


23 


Knee. 


Foot. 


21 


Foot. 


19 


Cranium and Face. 


Hip. 


13 


Hip. 


16 


Hip. 


Knee. 


10 


Elbow. 


9 


Sternum and ribs. 


Hand. 


9 


Hand. 


8 


Foot. 


Elbow. 


4 


Vertebra. 


7.5 


Elbow. 


Pelvis. 


3 


Tibia. 


4 


Pelvis. 


Cranium. 


3 


Cranium. 


4 


Tibia, Fibula, and 


Sternum, Clavicle, 




Pelvis. 


3.6 


Femur. 


and Ribs. 


3 


Sternum, etc. 


3.6 


Shoulder. 


Shoulder. 


2 


Femur. 


1.9 




Femur. 


1 


Shoulder. 


1.5 


Humerus. 


Tibia. 


1 


Ulna. 


1.4 


Ulna. 


Fibula. 


1 


Humerus. 


1 


Radius. 


Humerus. 


1 


Radius. 


0.7 


Scapula. 


Scapula. 


0.6 


Fibula. 


0.5 




Ulna. 


0.6 


Patella. 


0.1 



It is safe to state that before puberty the primary lesion in tuber- 
cular affections of joints is located in one or both of the epiphyses of 
the bones which enter into the formation of the joint, while in the adult 
primary tuberculosis of the synovial membrane is of more frequent 
occurrence. As age advances and the process of ossification is com- 
pleted, the predisposing localizing causes in bone apparently disappear, 
while the synovial membrane becomes more susceptible to primary 
localization. Of 204 specimens of tubercular joints obtained from 
patients of all ages, examined by Mueller, 158 were primary osteal, and 
46 primary synovial, tuberculosis. 

Artificial Tuberculosis of Bone Produced by Direct Intra-vascular 
Infection. — Wm. Mueller, formerly one of Konig's assistants, produced 
the characteristic clinical form of tuberculosis in bone experimentally 
by injecting tuberculous material into the nutrient artery of long bones. 
Konig for a long time had claimed that the wedge-shaped sequestrum, 
so constantly found in tubercular foci in the articular extremities of the 
long bones was due to occlusion of a small artery by a tubercular 
embolus. Mueller's experiments were undertaken to produce this con- 
dition artificially. He made 16 experiments on rabbits, injecting tuber- 
culous pus into the femoral artery, some in a peripheral, some in a 
central direction, without any positive results following. In a second 
series the same material was thrown directly into the nutrient arteries 
of the femur and tibia. Of 10 of these cases 2 showed a tubercular 
focus in the medulla of the diaphysis of the tibia ; in another case 
miliary tuberculosis in the femur and tibia, and in the latter bone a 
small caseous nodule in the spongy part which contained numerous 
bacilli. The animals were killed eight weeks after injection, and showed 



526 PRINCIPLES OF SURGERY. 

no evidences of organic disease except a few tubercles in the lungs. 
Twenty experiments were made on young goats, 5 on sheep, and 2 
on dogs. The tuberculous material was injected directly into the 
nutrient artery of the tibia, the tibial artery being tied above and below 
the junction with this vessel. Primaiy union of the wound was obtained 
in all cases except in one dog. In the dogs and sheep all experiments 
resulted negatively. In the goats bone affections were produced that 
were identical with tubercular bone-lesions found in man. Most fre- 
quently the disease was established in the diaplrvsis, cheesy masses and 
granulation tissue showing themselves in the medulla and cortical 
portion of the bone, or tuberculous osteomyelitis with or without 
sequestration. Typical lesions were also found in the ends of the bones, 
with and without implication of the adjacent joints. In 2 of these cases 
the epiphysis was affected, while in 3 the shaft was involved. The 
following experiment made by him furnishes a good illustration of the 
identity of the bone disease produced experimentally with the disease 
as it occurs in man. 

Tubercular material was injected into the tibial artery of a goat 3 
months old. Wound healed in eight da}^s. Some lameness four months 
later, -gradually increasing during the next nine months. At the same 
time a swelling appeared at the knee-joint. Tibia painful on outer side. 
Animal killed thirteen months after the injection. At the necropsy 
there was found a typical fungous disease in the knee-joint, most ad- 
vanced at the lateral aspects of the joint ; a wedge-shaped sequestrum 
in one of the tuberosities of the tibia, a small granulation mass in the 
centre of the head of the tibia, and two similar granulation masses in 
the lower epiphysis of the femur. Excepting the lymphatic glands of 
the knee-joint, no other organs were affected. In some of the cases, 
pulmonary tuberculosis, twice general miliary tuberculosis. The re- 
mainder of the animals were killed when the}' began to show lameness — 
fourteen days to thirteen months after infection. The tubercular lesions 
thus produced were examined for bacilli, and these were never found 
absent. The starting-point, in every instance, must have been a tuber- 
cular embolus in one of the ultimate minute branches of the nutrient 
artery near the epiphyseal extremity of the bone. 

Clinical and Bacteriological Researches. — Schuchardt and Krause 
examined a great variety of tubercular lesions, and came to the conclu- 
sion that tubercle bacilli can be found in them without exception, but, 
as a rule, few in number, and often only to be detected after long and 
patient search. The}' found them invariably present in cases of second- 
aiy and primary tuberculosis of sj r novial membranes, tuberculosis of 
bone, in tubercular abscesses, and in the latter cases not in the fluid 



TUBERCULOSIS OF BONE. 527 

contents, but in the granulations lining the abscess-wall. Renken found 
the bacillus of tuberculosis in all cases of spina ventosa which lie exam- 
ined. Mueller carefully studied numerous specimens of synovial and 
bone tuberculosis, with special reference to the existence of the bacillus 
of tuberculosis, and, although the results in a number of cases were 
negative, he believes that the most intimate and direct etiological 
relations exist between the bacillus and all tubercular lesions in bones 
and joints. Among others who have shown the never-failing presence 
of the bacillus in different forms of surgical tuberculosis, including 
bones and joints, may be mentioned Kanzler, Mogling, Bouilly, and 
Letulle. Tuberculosis of bone and fungous disease of joints, like lym- 
phatic tuberculosis, have been, and by some are still, regarded as scrofu- 
lous affections. Kanzler wished to make a distinction between scrofula 
and tuberculosis, as he found the bacilli not as constant in the former, 
and observed that, after implantation of tissue of what he regarded as 
scrofulous affections in animals, the process was slower than after inocu- 
lation with the products of recognized forms of tuberculosis. Letulle 
considers scrofula and tuberculosis as belonging to one and the same 
disease, of which the former constitutes the milder form, and appearing 
externally, while the latter represents the graver form, attacking by 
preference the internal organs. The points made by the last two authors 
are too unimportant for further consideration as a scientific, or even 
practical, distinction between scrofula and tuberculosis as applied to 
affections of the bones or any other organs. The surgeon must recognize 
every lesion as tubercular in its origin, nature, and course in which the 
bacillus of tuberculosis can be found, from which successful cultivations 
can be made, and with which the disease can be artificially produced in 
animals by inoculation. The presence of the bacillus of tuberculosis in 
the body and its localization in the medullary tissue of bone is the con- 
ditio sine qua non in the causation of osseous tuberculosis. The influence 
of traumatism in the etiology of tuberculosis of the bones and joints 
has been greatly overestimated. Traumatism as an etiological factor 
occupies a subordinate role, inasmuch as it only proves, at least, as an 
exciting cause in persons alreacty infected with the essential cause. Max 
Schiiller proved experimentally in animals infected with tuberculosis 
(for instance, through the respiratory tract) that a slight traumatism 
to a joint would determine localization of the microbes floating in the 
blood-current in the part injured, and that a tubercular S3aiovitis or 
pararthritis would follow. 

Clinically, tuberculosis of the bones can be traced only in a small 
per cent, of the cases to a traumatic origin. It is, as Volkmann asserted 
long ago, characteristic that the traumatism is always slight, often quite 



528 PRINCIPLES OF SURGERY. 

insignificant ; tuberculosis of bone, even in tubercular subjects, seldom, 
if ever, follows a fracture, as the injury in such cases is productive of 
such active cell proliferation that will neutralize the pathogenic action 
of the bacilli, which might reach the seat of injury with the extravasated 
blood. It is also possible that in many cases, at least, the attention of 
the patient or his Mends is first accidentally called to an existing tuber- 
cular focus by the immediate effects of the injury, the latter having had 
no influence in the causation of the disease. Every child large enough 
to run around injuries himself more or less (almost) daily, and yet tuber- 
culosis of the bones and joints follows as a consequence only in compar- 
atively few, and in such cases the essential cause must be present in the 
blood or tissues at the time the injury is received. As has been previ- 
ously stated, what is generally regarded as local bone tuberculosis (by 
which we mean the absence of recognizable tubercular lesions in other 
organs) is in reality a secondary disease, resulting from the introduction 
of bacilli through the respiratory or alimentary tract into the circulat- 
ing blood, with localization in the bone, or the entrance of bacilli into 
the circulation from a pre-existing but undetectable tubercular product, 
with secondary localization in bone. In this sense a primary, or, to use 
a more correct expression, a localized osseous or articular tuberculosis 
is, according to Kummer, found in about 40 per cent, of the cases ; in 
the remaining 60 per cent, depots are found at the same time in other 
organs of the body ; the lung comes first, with 25 per cent. ; other joints, 
10 per cent. ; other bones, 10 per cent. ; lymphatic glands, 10 per cent. ; 
peritoneum, 3 per cent. ; pleura, 2 per cent. 

Pathology and Morbid Anatomy. — The tubercle bacillus has a special 
predilection for the medullary tissue of the bones, and especially for 
the red medullary tissue in the cancellated tissue in the region of the 
epiphyseal cartilage of the long bones. As an inflammatory affection it 
is more correct to speak ol tubercular osteomyelitis than tuberculosis 
of bone, since the medullary tissue and the blood-vessels which it con- 
tains are the parts that take an active part in the inflammatorj' process. 
The anatomical conditions of the vessels in the epiphyseal region of the 
long bones in young persons, and in the vessels of the medullary tissue, 
favor implantation of the microbes upon the vessel-wall, and they also 
explain the frequency with which localization of the tubercular process 
takes place in this locality. The shaft of the long bones is generally 
exempt from tubercular disease with the exception of the phalanges of 
the fingers and toes and the metacarpal and metatarsal bones in chil- 
dren, where the tuberculous osteomyelitis gives rise to the well-known 
spina ventosa of the old authors. As soon as embolic infection in bone 
has taken place a process of osteoporosis and decalcification occurs 



TUBERCULOSIS OF BONE. 529 

around the tubercular embolus or thrombus, and the pre-existing medul- 
lary and connective tissues are transformed into embryonal or granula- 
tion cells, which impart to the product of the specific inflammation its 
characteristic fungous appearance. It is not often that only a single 
focus of tubercular infection in bone is present ; more frequently two or 
three foci appear in the same region simultaneously or in slow or 
rapid succession, and it is not unusual to find that two neighboring 
epiphyses are infected at the same time or during the course of the dis- 
ease. In bone the granulation tissue undergoes the same series of sec- 
ondary degenerative tissue changes as in the lymphatic glands ; hence 
in advanced cases we expect to meet with caseation, liquefaction of the 
cheesy material, and suppuration in cases of secondary infection with 
pyogenic microbes. The obstruction of a small arter}^ by an embolus or 
thrombus which contains tubercle bacilli usually leads to necrosis and 
sequestration of a triangular piece of bone, which, in its outlines, marks 




Fig. 156.— Tubercular Focus near the Epiphyseal Line of the Lower 

End of the Femur. 

the area of tissue which received its blood-supply from the obstructed 
vessel ; thus the triangular sequestra are formed that are so frequently 
met with in osteal tuberculosis of the epiphyseal extremities. ' If the 
embolus is located on the side of the epipli3 T seal cartilage toward the 
joint, the base of the triangular sequestrum is directed toward the joint, 
and not infrequently projects slightty into the joint. It is seldom that 
tuberculosis of bone develops in the course of pulmonary tuberculosis, 
but pulmonary and diffuse miliary tuberculosis can be traced frequently 
to a tubercular osseous focus. The intimate relations which exist 
between the tubercular nodule in bone and the blood-vessels furnish a 
satisfactory explanation of the frequenc} r with which systemic infection 
takes place. A person once infected with the bacillus tuberculosis is 
liable to suffer from the different forms of localized tuberculosis, and 
finalty dies of pulmonary or general miliary tuberculosis. Volkmann has 
well said that a child suffering from glandular tuberculosis has a good 
chance to become the subject of osseous tuberculosis during adolescence, 

34 



530 PRINCIPLES OF SURGERY. 

and to die of pulmonary tuberculosis before reaching the age of 30. As 
soon as the granulation process in bone reaches an adjacent vein, the 
tissues constituting the vein-wall undergo the same process, the bacilli 
reach the lumen of the vessel and re-enter the s}^stemic circulation, and 
give rise to miliary tuberculosis in organs which are anatomically pre- 
disposed to secondary infection. As long as decalcification of the sur- 
rounding bone goes on the infection is progressive, but as soon as 
osteosclerosis takes its place the process becomes limited ; the micro- 
organisms are shut in, as it were, by an impermeable wall of sclerosed 
bone. The most unfavorable conditions are created in cases in which 
the tubercular focus becomes the seat of secondary infection with 
P3^ogenic microbes, as the suppurative process opens up to the bacillus 
of tuberculosis new areas for invasion in which the resistance of the 
tissues to tubercular infection has already been greatly diminished. It 
is also during the suppurative stage that joint-complications are most 




Fig. 157.— Tubercular Cavity in the Internal Condyle of the Femur. 

(Landerer.) 

likely to arise. The clinical history of cases of tuberculosis of bone, as 
well as the macroscopical and microscopical appearances of the lesion, 
are typical of tuberculosis as found in other organs. The crucial test 
which proves the tubercular character of most of the chronic inflamma- 
tory affections of bone in children has been furnished by bacteriological 
investigations and experimental research. Most of the investigators 
who have studied this subject agree that in tubercular bone affections it 
is sometimes very difficult to find the bacillus, that it is not found in 
great abundance, and that sometimes it has evaded even the most careful 
search. According to Kdnig, who is authority on everything that per- 
tains to tuberculosis of bones and joints, all cases of osteotuberculosis 
can be arranged under four principal groups, according to the predomi- 
nating pathological conditions of the lesions : 1. The granulating focus. 
2. The tubercular necrosis. 3. The tubercular infarct. 4. Diffuse 
tubercular osteomyelitis. 



TUBERCULOSIS OF BONE. 



531 



1. The granulating focus is found as single or multiple, round or 
oval, cavities, from the size of a millet-seed to that of a pea or hazel-nut, 
containing living embryonal tissue, or, if this has been destroyed by 
coagulation necrosis and caseation, a yellowish-gray, cheesy material, or 
liquid tubercular pus. Minute spiculae of bone are imbedded among 
the granulations or suspended in the liquefied caseous material. Histo- 
logically, the granulation material is composed of the same cell-elements 
as recent tubercle in other organs, only that, as a rule, the giant cells are 
more numerous and of larger size. If caseation has taken place the 
cheesy material is surrounded by a zone of granulation tissue. As long 
as the process has not come to a stand-still the surrounding bone is 
osteoporotic, and can be easily scraped out with a sharp spoon. As soon 



•?:?:°°: % ) : i*\&^&°??0f&fQ 







— Tn 



Fig. 158.— Tuberculosis of Astragalus. (Tillmanns.) 

Tu, fungous granulations and tubercle in spongiosa ; K, remaining laminae. 



as the inflammatory process has subsided the osteoporotic bone becomes 
sclerosed and the tubercular focus is walled in and, for the time being, 
is rendered harmless. Cheesy tubercular cavities in bone resemble the 
same condition in the lungs, only that secondaiy infection with pus- 
microbes is of less frequent occurrence, and on this account the cavity 
never attains such large size as in the latter organ. 

2. Tubercular necrosis necessarily follows if the infected area exceed 
the size of a hazel-nut. The non-vascular structure of the tubercular 
product and the blocking and destruction of blood-vessels during the 
early stages of the tubercular inflammation produce earty death of the 
bone, corresponding to the limits of the inflammation, and if this exceed 
the resorption capacity of the granulations the dead tissue is not 
removed by absorption, and is found as a sequestrum as soon as it has 



532 



PRINCIPLES OF SURGERY. 



become detached from the surrounding healthy bone. If the tubercular 
process lias been rapid and the granulation tissue is scanty, the necrosed 
bone is not osteoporotic; but if the disease has pursued a more chronic 
course, and has resulted in the production of an abundance of granula- 
tion tissue, it presents a honey-combed appearance, is irregular in shape 
and in size, does not correspond with the area of the infected district, as 
part of it has been absorbed by the granulations. Its color depends on 




Fig. 159.— Tubercular Sequestra. (Landerer.) 

the condition of the granulations which surround it ; if these have not 
undergone secondary degenerative changes it may resemble healthy 
bone, but if caseation has taken place it is infiltrated with the cheesy 
material, and then presents a grayish-yellow or j^ellow appearance. If 
the necrosed bone has undergone no reduction in size, and the granula- 
tions surrounding it are few, it remains firmly wedged in position, 
and under such circumstances it is often difficult to locate the exact 




Fig. 160.— Tubercular Infarct in the Head of the Femur. Cartilage Separated 
from the Wedge-shaped Sequestrum. (Volkmann.) 

boundary-line between it and the surrounding healthy bone or to dis- 
lodge it from its position. 

3. The tuberculous infarct is only another form of tubercular 
necrosis, and is separately classified because the necrosed bone is always 
wedge-shaped, and the necrosis has been caused by the impaction of an 
embolus containing tubercle bacilli in a distal branch of a nutrient 
artery. The size of the vessel obstructed by an infected embolus will 



TUBERCULOSIS OF BONE. 533 

determine the extent of the necrosis. If the embolus is small, the area 
of necrosis may be increased by the blocked vessel becoming the seat of 
secondary thrombosis, obliteration of the vessel taking place in a proxi- 
mal direction by growth of the thrombus toward the heart. As the 
cortical portion of the bone is seldom involved by a tubercular infarct, 
the necrosed area is often overlooked in operations on tubercular joints 
unless the bone is sawn through. If the base of the wedge-shaped piece 
project into a joint that has been used, its surface will be found smoothly 
polished by the movements in the joint. Separation of the sequestrum 
takes place more slowly than after suppurative osteomyelitis, the process 
requiring often, according to the size of the sequestrum and the activity 
of the inflammatory process, months and years for its completion. If 
the granulations which surround the sequestrum do not undergo cheesy 
degeneration, the bone becomes imbedded and fits accurately into the 
cavity, and if the surrounding zone of granulation is converted into 
connective tissue it may become permanently encapsulated ; but even 
from such an apparently healed depot local and general infection can 
occur at any time. 

4. The diffuse form of tubercular osteomyelitis is quite rare. The 
pathological and clinical characteristics of this form of local tuberculosis 
consist in the rapid local extension of the affection and the danger to 
life from general infection. On making a longitudinal section through 
a long bone affected by diffuse tubercular osteomjelitis, we observe 
conditions which closely resemble acute suppurative osteomj^elitis. We 
find large, irregular, often multiple areas of a 3'ellowish-white infiltration 
with multiple foci of liquefied chees}^ material. The infection extends, 
as in cases of suppurative osteomyelitis, along the blood-vessels and 
Haversian canals to the periosteum, resulting in diffuse plastic peri- 
ostitis with the formation of irregular, diffuse masses of bone. In 
these cases there is no tendency to limitation in the formation of 
sequestra, but rather a tendency to spread indefinitely, and to invade 
even the medullary tissue of the shaft. Patients suffering from this 
form of tubercular osteom3 T elitis are exposed to/the dangers of a fatal 
general tuberculosis if the infected tissues are not removed by a timety 
and thorough operation. In operating it is important to recognize this 
form, since it requires more radical measures, — either amputation or very 
extensive excision of the entire thickness of the affected bone. Local 
operations such as will meet the indications in the other varieties of 
osteotuberculosis are of no avail. With the exception of this form of 
tuberculosis of bone the periosteum seldom participates in the tubercular 
inflammation. When the dry granulating focus reaches the periosteum, 
a small, soft, elastic, limited granulation swelling forms, — first under the 



534 PRINCIPLES OF SURGERY. 

periosteum, later outside of it. It is characterized by slow growth, 
comparatively little pain, slight tenderness, and a tendency to -remain 
stationary for a long time. If, however, the central focus has become 
cheesy, and the liquefied cheesy material comes in contact with the peri- 
osteum and the paraperiosteal tissues, a large tubercular abscess forms 
in a short time. As soon as the periosteum has been perforated the 
cheesy material infects the connective tissue, which then takes an active 
part in the formation of the tubercular abscess. Before such an abscess 
ruptures spontaneously the skin overlying it becomes tubercular and 
presents, at the point of perforation, the appearance of lupus. 

Symptoms and Diagnosis. — The general symptoms are often no indi- 
cation of the existence or extent of the local disease, as patients with 
quite extensive osteotuberculosis may present every appearance of per- 
fect health. More than fifteen years ago Konig called our attention to the 
fact that a slight rise in the temperature is frequentlj T present even in 
cases of limited local tuberculosis. If the thermometer show a normal 
morning temperature and a slight rise toward evening, if not more than 
half a degree Fahrenheit, but continued for weeks, it indicates a careful 
search for a local tubercular focus. Progressive anaemia is alwa} T s an 
unfavorable symptom, as it indicates either the presence of additional 
foci in important organs or accompanies the exhaustive purulent dis- 
charges after secondary infection with pus-microbes. The occurrence 
of mixed infection, with or without a direct infection-atrium, is usually 
announced by a high temperature and other symptoms of septic infection. 
The local symptoms vary according to the location, condition, and size 
of the tubercular focus and the presence or absence of complications. 

I. Pain. — Pain is an almost constant symptom, but its intensity is 
subject to great variation. Unlike in acute suppurative osteomyelitis, 
the inflammatory product does not give rise to the same degree of 
tension; hence pain is not so severe. The primary exudation in tuber- 
cular inflammation is always scant}^, and the inflammatory product is 
composed mostly of granulation tissue derived from pre-existing cells ; 
at the same time the surrounding bone-tissue becomes osteoporotic, 
consequently tension is to a great extent avoided and pain is either 
slight or entirely absent. Children suffering from spina ventosa com- 
plain of little pain, although a phalanx of a finger may be almost 
completer^ destroyed by a tubercular osteomyelitis. In such cases the 
granulation tissue is formed slowly, the compact layer of the bone is 
rendered osteoporotic, and generally yields to the intra-osseous pressure 
and expands perhaps to twice its normal thickness; pain is slight or 
entirely absent, because no great intra-osseous tension has occurred. 
That tension or pressure greatly aggravates pain in osseous tuberculosis 



TUBERCULOSIS OF BONE. 535 

is one of the most familiar facts in surgery. Pain is promptly relieved 
in a case of tubercular spondylitis by suspension and rest in the recum- 
bent position, and greatly aggravated by flexion of the spinal column 
which necessarily produces pressure upon the bodies of the inflamed 
vertebrae. In osteo-arthritis of the large joints pain is relieved by rest 
and extension, and is always increased by use of the limb or by pressing 
the inflamed articular surfaces against each other. It may be stated as 
a rule, that the intensity of the pain bears a direct relationship to the 
acuteness of the inflammatory process. The pain is intermittent and 
more severe during the night. The nocturnal exacerbation of the pain, 
as evidenced in children by restlessness during sleep, moaning, grinding 
of teeth, and horrible dreams, is often one of the first symptoms which 
excites suspicion of the existence of osteotuberculosis. The pain is not 
always referred to the seat of lesion. Tubercular osteomyelitis of the 
head and neck of the femur gives rise to pain in the region of the knee- 
joint, and children suffering from tuberculosis of the spine usually refer 
all the suffering to the pit of the stomach or to some other part of the 
abdomen supplied with nerves that take their exit from the spinal canal 
at a point corresponding to the inflamed vertebra. 

2. Tenderness. — The existence of tenderness over a point corre- 
sponding to a tubercular focus in the interior of a bone is one of the 
surest indications of the existence of osteotuberculosis. In many cases 
of epiphyseal tuberculosis patients have been treated for some supposed 
lesion in the adjacent joint simply because this symptom was not care- 
fully searched for, or, if discovered, its significance was misinterpreted. 
In such cases the existence of a circumscribed point of tenderness in the 
epiphyseal line and the absence of lesions in the joint will enable the 
surgeon to locate accurately a focus in the interior of a bone. If more 
than one focus is present in the epiphyseal extremity of a long bone the 
number of tender points will correspond with the number of foci in the 
bone. Whether a central focus in a bone could be always recognized by 
relying upon this symptom is somewhat doubtful, but usually the foci 
are located sufficiently near the surface of the bone to give rise to tender 
points, which can be readily located by finger pressure. 

3. Swelling. — External swelling is absent until the atrophic layer 
of compact bone yields to the intra-osseous pressure, as may be seen in 
advanced cases of spina ventosa, or until by pressure atrophy over the 
centre of the focus the compact layer is perforated, and a soft, circum- 
scribed, boggy swelling forms underneath the periosteum. If the granu- 
lation tissue has retained its vitality the extra-osseous swelling increases 
very slowly in size, and there is no tendency to diffuse infection of the 
connective tissue after the granulations have reached the paraperiosteal 



536 PRINCIPLES OF SURGERY. 

tissues. Pseudofluct nation is generally present, and many such granu- 
lating foci at this stage have been carelessly incised under the mistaken 
diagnosis of abscess. If the central focus has undergone caseation 
before the periosteum is perforated, then the paraperiosteal tissues 
become rapidly infected, and a tubercular abscess, such as has been 
described before, develops in a short time. The abscess wanders away 
from the place where it originated in directions offering the least resist- 
ance, along preformed anatomical spaces and in obedience to the law of 
gravitation. The size of such an abscess is, absolute^, no indication of 
the extent of the primary lesion in the bone, as a minute focus may be 
the cause of a large abscess and a small abscess may mark the location 
of an extensive primary lesion. (Edema is usually not well marked, 
even if the abscess is large, unless secondary infection with pyogenic 
microbes has occurred. The diffuse form of tuberculous osteomyelitis is 
alwaj^s attended by a plastic osteomyelitis, and, consequently, the early 
appearance of external swelling is one of the points to be taken into 
consideration in differentiating between the different forms of osteo- 
tuberculosis. The swelling that attends tuberculosis in bones deeply 
seated, as the vertebrae, hip-joint, and pelvic bones, does not become 
apparent until the existence of a tubercular abscess indicates the probable 
seat of the primary lesion. 

4. Redness. — The skin over a tubercular focus in the interior of a 
bone or over a tubercular abscess presents a normal appearance until it 
has become infected and shows other unmistakable signs of tubercu- 
losis. This does not occur until the granulations have permeated the 
deeper portions of the skin, or until the caseous material has only the 
skin for its covering. Under such circumstances the skin presents a 
dusk}r-red hue, owing to impaired capillary circulation, and becomes 
more and more attenuated by pressure atrophy and destructive changes 
until it finally yields to the pressure from beneath, and spontaneous 
evacuation of the contents of the abscess takes place. If the subcuta- 
neous product is composed of granulation tissue the undermined skin, 
after perforation has taken place, is destroyed by degrees and the part 
presents the appearances of lupus. 

5. Atrophy of Limb. — Muscular atrophy is almost a constant symp- 
tom in osteotuberculosis as well as in tubercular synovitis. This atroplry 
is not caused altogether by inactivity of the limb, and it appears to be 
due in part, at least, to tropho-neurotic lesions. 

Besides a careful study of the clinical histoiy, several diagnostic 
measures may be resorted to in doubtful "cases to enable the surgeon to 
make a positive diagnosis. 

Means of Differential Diagnosis — (a) Akidopeurastik. — Exploration 



TUBERCULOSIS OF BONE. 537 

of a doubtful swelling with a strong steel needle was introduced by Mid- 
deldorpf for the purpose of ascertaining the consistence and probable 
structure of the tissues composing the swelling. He called this simple 
procedure akidopewastik. The presence of a tubercular focus in the 
interior of a bone can often be demonstrated by this aid to diagnosis 
before any external swelling has appeared. A strong needle of an hypo- 
dermic syringe can be used for exploring a bone the density of which 
has been diminished by chronic inflammation, if this latter lias not 
been followed by osteosclerosis. During the active stage of osteo- 
tuberculosis the bone for a considerable distance around the focus is 
osteoporotic, and can be readily penetrated by a strong, sharp needle. 
The exploration should be made under strict antiseptic precautions. 
The puncture is made in the centre of the tender area, and in a direction 
corresponding to the probable location of the central focus. If the 
needle meet with any considerable resistance in the bone, it is advanced 
by rotatory movements ; the arrival of the point in the granulating 
centre or caseous focus is announced by a sudden loss of resistance. 
By advancing the needle sufficiently to touch the opposite side of the 
cavity its probable size can be ascertained. 

(b) Exploratory Puncture, with Aspiration. — If the needle of an ex- 
ploratory or hypodermic syringe is used to make the akidopeurastik, 
exploration of the bone may be followed b}^ removing some of the con- 
tents of the cavity for examination by aspiration. If the tubercular 
product has undergone caseation and liquefaction some of the cheesy 
material can be removed by aspiration, and the nature of the lesion may 
then be revealed by positive demonstration. If still further evidence is 
required, a guinea-pig may be inoculated with the same needle, which 
still contains enough of the material to produce a positive result in the 
animal. If the cavity contain granulation tissue little fragments of this 
can be drawn into the needle, and with these inoculation experiments for 
diagnostic purposes can be made. In tubercular necrosis it may be pos- 
sible to detect the presence of the sequestrum and ascertain its mobility 
by exploratory puncture. If a tubercular abscess has formed, the char- 
acter of the contents of the swelling may be ascertained by using the 
exploratory syringe, and the nature of the primary cause demonstrated, 
if need be, by injecting the material aspirated into the subcutaneous 
tissue or peritoneal cavity of a guinea-pig. In the differential diagnosis 
of tuberculosis of bone, it is necessary to exclude synovial tuberculosis, 
sarcoma, echinococcous cyst, rachitis, suppurative osteon^elitis, and 
sj'philis. Many cases of primary tuberculosis of bone have been mistaken 
for synovial tuberculosis, and vice versa. Primary tuberculosis of bone 
frequently results in contractures of joints without direct implication of 



538 PRINCIPLES OF SURGERY. 

the joint, and this has often led to a wrong diagnosis. In primary syno- 
vial tuberculosis the first pathological changes occur in the joint, and no 
tender points will be found in the epiphyseal regions. In osteotubercu- 
losis not complicated b} r an extension of the disease to the adjacent joint 
the first symptoms are referred to the lesion existing in the interior of 
the bone, and it is usually not difficult to ascertain the existence of cir- 
cumscribed points of tenderness which correspond to the location of 
the foci. Periosteal sarcoma is, from the beginning, an extra-osseous 
product. Central sarcoma, as a rule, increases more rapidly in size than 
a tubercular swelling, and is often the seat of pulsations and a blowing- 
sound which can be heard by auscultation. Central sarcoma is often the 
cause of a pathological fracture, while this accident is exceedingly rare 
in osteotuberculosis. Echinococcus of bone is an exceedingly rare 
affection, but, as it ma}^ simulate osteotuberculosis, differential diagnosis 
must be based on an exploratory puncture, which will yield a clear serum 
containing the characteristic hooklets in the former instance, and granu- 
lation tissue or the products of caseous degeneration in the latter. 
Rachitis gives rise to swelling and pain in the epiphyseal regions ; but 
this affection is not limited to one or two bones, and affects almost every 
bone in the body alike. Epiplryseal multiple osteomyelitis is an acute 
or, at least, subacute affection, and results early in the formation of puru- 
lent foci, and is often attended b} T epiphyseolysis. The virus of syphilis 
has a special predilection for the periosteum, while this structure is 
almost immune to primary tubercular affections. In 95 out of every 100 
cases chronic inflammation in bone means tuberculosis, and, unless there 
are special reasons which should render the diagnosis doubtful, it is safe 
to adopt a treatment adapted for tubercular osteomyelitis in almost 
every case where the symptoms point to a chronic inflammation and the 
existence of a tumor or parasitic growth can be excluded. 

Prognosis. — On the whole, the prognosis is more favorable in cases 
of osteotuberculosis than if the tubercular infection is located in the 
skin, a joint, lymphatic gland, or any of the internal organs. Spontaneous 
healing of a tubercular focus in bone is possible under favorable con- 
ditions. Everything that adds to the patient's strength and power of 
resistance to the microbic infection adds to the possibility of such a 
favorable termination. If the patient is well nourished, and, above all, 
if the blood is in a normal condition, limitation of the disease may occur 
before caseation has taken place ; and if cheesy material has formed, and 
it can be removed by operative interference, the prospects of a perma- 
nent recovery are good. It must be, however, admitted that every person 
who has suffered from an attack of osteotuberculosis during childhood 
or youth, even if an apparent perfect cure has been effected spontaneously 



TUBERCULOSIS OF BONE. 539 

or by operative measures, is always in danger of becoming the subject 
of re-infection at any subsequent time. The spores of the bacillus of 
tuberculosis may remain in a latent condition for an indefinite period of 
time in the cicatrized primary lesion, to become a cause of subsequent 
danger as soon as the local or general conditions enable them to exercise 
their pathogenic properties. Healing by cicatrization is possible in the 
small granulating foci so long as the coagulation necrosis is limited and 
no caseation has occurred. In such cases the embryonal cells are con- 
verted into permanent connective tissue and the small fragments of bone 
are removed by absorption, while the bone around the cicatrix becomes 
sclerosed. If caseation has occurred, but the cheesy material has not 
undergone liquefaction, encapsulation of the tubercular product can take 
place by the wall of granulation tissue lining the cavitj' becoming con- 
verted into cicatricial tissue, forming a capsule, which, for the time being 
at least, mechanically prevents the local extension of the disease. Small 
sequestra may become imbedded in a connective-tissue capsule in a 
similar manner. If the sequestrum is large it will act like every other 
foreign infected body, and sooner or later require an operation for its 
extraction. If the tubercular process has extended to a joint, the prog- 
nosis is more grave, and the chances for a spontaneous recovery are 
much diminished. The prognosis is always more grave, other things 
being equal, if the bone affected is so located that removal of the pri- 
mary focus by operative treatment is anatomically impossible. The 
danger to life and the probability of local extension are always greater 
if the granulation tissue has been destined by coagulation necrosis and 
caseation, as the granulation tissue is one of the means by which regional 
and general infection are prevented. The danger to life is imminent if a 
large tubercular abscess has become infected with pus-microbes, as the 
secondary infection results in destruction of the granulation tissue lining 
the cavity, which favors the local and general extension of the tuber- 
cular infection, and at the same time brings sepsis, exhaustion from pro- 
fuse suppuration, and amyloid degeneration of important internal organs 
as additional elements of danger. The prognosis is alwaj's more grave 
in persons advanced in years than in children, as limitation of the dis- 
ease occurs more frequently in the latter. 

Treatment. — The medical treatment in patients suffering from osteo- 
tuberculosis must be tonic and supporting. Dietetic and hygienic treat- 
ment is of more value than the administration of drugs. Sea-bathing 
and change of climate will often accomplish more than bitter tonics, iron, 
quinine, arsenic, and codliver-oil. The prolonged internal administration 
of guaiacol or one of its preparations should alwa}^s be resorted to. The 
local treatment, short of a radical operation, must consist in the use of 



540 PRINCIPLES OF SURGERY. 

such means as will aid the natural resources in effecting limitation of 
the tubercular process, of which the most important is 

I. Physiological Rest. — The importance of securing for the inflamed 
part, as near as can be done by mechanical support, absolute physio- 
logical rest cannot be overestimated. The process of repair in a tuber- 
cular focus often meets with great and insurmountable difficulties. The 
embryonal cells, of low vitality almost from the beginning, are poisoned 
as soon as born with the ptomaines of the bacillus of tuberculosis, and 
consequently are converted iuto tissue of a higher type only under the 
most favorable conditions. The non-vascularity of tubercle tissue is an- 
other cause why the inflammatory product so seldom takes an active part 
in the process of repair. The first indication in the treatment of a tuber- 
cular osteomyelitis is to secure for the part a favorable condition of the 
circulation, which can onty be done by securing rest. The most efficient 
way to procure rest, not only for the diseased part, but for the entire 
bod}', is to confine the patient to bed ; but, as these affections are noted 
for their chronicit} 7 , lasting for months and years, enforced rest by this 
method would seriously impair the general health, and on this account it 
is advisable, in the majority of cases, to resort to one of the numerous 
mechanical appliances which will immobilize the part; while, at the same 
time, the patient can avail himself of the benefits to be derived from 
out-door air and change of scenery and surroundings. 

In tuberculosis of the spine Sayre's plaster-of-Paris jacket, applied 
while the patient is partly suspended, answers a more useful purpose 
than any of the numerous complicated apparatuses which have been as 
yet devised. To apply the jacket properly requires a great deal of ex- 
perience and the exercise of considerable skill. In many communities 
this method of treatment has become unpopular, both among physicians 
and the laity, from the bad results caused b}' improper applications of the 
jacket. Hy perextension must be avoided, and the patient must be 
instructed to extend himself only until pain is relieved and not beyond 
this point. The boi^ prominence at the seat of curvature must be 
carefully protected against pressure by applying on each side a firm pad 
sufficiently thick to prevent contact of the projecting spinous processes 
with the plaster cast. The plaster bandages themselves must be applied 
smoothly, so that after extension is removed the jacket will closely fit 
the unequal surface of the body. Another matter of great importance 
is to see the patient from time to time, in order to determine whether 
the jacket causes injurious pressure at any point, which, if this should 
be the case, is remedied at once, either by cutting out that portion of 
the jacket which has caused the decubitus or by applying a new one. In 
tuberculosis of any of the bones of the extremities rest can be secured 






TUBERCULOSIS OF BONE. 541 

most efficiently by immobilizing the limb in a plaster-of-Paris dressing. 
The splint must always include one or more of the adjacent joints. 
Undue constriction of the limb is prevented by interposing between it 
and the splint a thin layer of salicylized cotton. If the disease affect 
any of the bones of the lower extremities the patient must not be 
allowed to walk without crutches. 

2. Ignipuncture. — During the early stages of osteotnberculosis excel- 
lent results have been obtained by ignipuncture, — a method of treatment 
devised by Richet in 1870. If a tubercular focus can be accurately 
located, this method of treatment should receive a trial, as it is not 
attended by any risks and frequently effects a permanent cure. The 
field of operation is thoroughly disinfected, and, with the needle-point of 
a Paquelin cautery heated to a dull or red heat, the soft tissues and bone 
are perforated. In making the perforation it is necessary to advance the 
point slowly and to remove it from time to time and revive the heat in 
order to prevent impaction of the point. The entrance of the pointing in- 
strument into the cavhVy or tubercular focus can be readily felt, as resistance 
at that moment is suddenly diminished. The therapeutic effect of igni- 
puncture is threefold : 1. The tunnel made establishes free drainage and 
relieves promptly the intra-osseous tension. 2. At least a portion of the 
infected tissue is destro} r ed by the heat. 3. A plastic osteomyelitis is 
excited in the vicinity of the track and in the cauterized portion of the 
cavity, which exerts a favorable influence in bringing about limitation of 
the disease, or even in effecting a final cure. Through the opening made 
iodoform can be introduced into the cavity, which offers additional ad- 
vantage in treating osseous foci successfully b}r this procedure. To 
insure a successful issue it is absolutely necessary to prevent infection 
with pus-microbes through the opening by making the operation under 
strict antiseptic precautions, and protecting the puncture with an efficient 
antiseptic absorbent dressing until it is completely closed by cicatrization 
and epidermization. Ignipuncture is most useful in the treatment of 
accessible foci in the epiphyseal extremities of the long bones and during 
the early stages of tuberculosis of the wrist and tarsus. In insipient 
tuberculosis of the tarsus I have repeatedly obtained a satisfactory and 
permanent result by making an opening through the entire tarsus from 
side to side, in a line of the disease, by inserting the point from each 
side, the two tunnels meeting in the centre. Ignipuncture always relieves 
the pain promptly, and the track made is completely closed by permanent 
tissue in the course of a few weeks. 

Parenchymatous Injections of Iodoform. — In foci accessible to 
puncture parenchymatous injections of a 10-per-cent. iodoform-glycerin 
emulsion deserve a faithful trial. This method of treatment is of special 



542 PRINCIPLES OF SURGERY. 

value in cases in which the bone affection has resulted in the formation 
of a tubercular abscess. In such instances not only the abscess-cavity, 
but the tissues at the primary focus should be iodoformized. 

3. Radical Operation — (a) Removal of Limited Foci. — The radical 
treatment of tuberculosis of bone consists in the complete removal of 
the infected tissues by operative interference. The success which follows 
this treatment is most marked in cases where caseation has not taken 
place, — that is, in the granulating form, — and in other forms where the 
operation is performed before extensive secondary pathological con- 
ditions have occurred. The operation is indicated as soon as a positive 
diagnosis can be made, and after the milder measures have proved use- 
less in arresting the progress of the disease. Timely surgical inter- 
ference in osteotuberculosis is not only calculated to become the surest 
means of preventing general infection, but it also has for its object the 




Fig. 161.— Central Tuberculosis of the Neck of the Femur. (Volkmann.) 

limitation of the disease by the removal of the primary cause, and by 
accomplishing these objects it becomes at once a prophylactic as well as 
a curative measure. If a tubercular focus or foci can be removed by a 
radical operation before the adjacent joint has become infected, then the 
operation has not onty been successful in effecting a permanent cure, but 
it has also been instrumental in preventing the extension of the disease 
to the joint. If the operation is undertaken at a time, as it should be, 
before any external swelling has appeared, the surgeon must be guided 
in finding the focus by searching for tender points, aided, if necessary, 
by exploratory punctures. As in epiphyseal tuberculosis the foci are 
always near a joint, the incision for exposing the bone should be made in 
such a manner as to avoid opening the joint. A case of central tubercu- 
losis of the neck of the femur, as shown in Fig. 161, was subjected to a 
successful extra-articular operation b}< Yolkmann. If the focus be so 



TUBERCULOSIS OF BONE. 543 

close to the joint as to make it necessary to remove bone underneath the 
insertion of the capsule or ligaments of the joint, it is advisable to lift 
the periosteum with the joint-structures from the bone to some distance 
from the incision, and in this manner avoid injury to the joint. The 
bone overlying a tubercular focus or abscess is usually softened and 
easily removed with a small, round chisel. The limb should alwaj s be 
rendered bloodless by using Esmarch's constrictor, so that the operator 
can identify the tissues as they are being removed during the operation. 
If, after tunneling the bone for a considerable distance, the focus be not 
found, it is advisable to make from this track exploratory punctures in 
different directions with a small perforator until the cavity is found, 
which is then freely exposed with the chisel. As soon as this has been 
done the sharp spoon is used, with which the necrosed bone, granulation 
tissue, or cheesy material is removed. The osteoporotic bone in the 
immediate vicinity of the cavity is removed in a similar manner, and the 
surgeon must assure himself, by repeated examinations of the tissue 
removed, that healthy tissue has been reached before the sharp spoon is 
laid aside. 

If any doubt remain whether all of the infected tissue has been 
removed, it is better to resort to ignipuncture, perforating the bone at 
different points to the depth of a few lines with the sharp point of a 
Paquelin cautery in addition to the curetting. This procedure will 
destroy at least some of the bacilli which might have remained, and will 
incite a plastic osteom3 r elitis that will effectually resist the pathogenic 
action of such microbes that still remain. After the cavity has been 
thoroughly irrigated with an antiseptic solution it is dried, iocloformized, 
and packed with antiseptic decalcified bone-chips. The periosteum is 
separately sutured over the bone-packing, sufficient space being left to 
insert, at the lower angle of the wound, a few threads of catgut to serve 
as a capillary drain. The remaining tissues are included in the super- 
ficial sutures and an antiseptic dressing applied. The limb must be 
immobilized by applying a well-padded posterior splint. If all the 
infected tissues have been removed and no infection with pus-microbes 
have taken place during or after the operation, the wound unites under 
one dressing in from one to two weeks, and the definitive healing of the 
cavity is completed in the course of three to six weeks, according to the 
condition and age of the patient and the size of the cavity. The packing 
of such cavities with iodoformized decalcified bone-chips is an important 
element in the prevention of a local recurrence and general infection, and 
in securing satisfactory healing of the wound and complete restoration 
of the lost parts. Should suppuration follow the operation, secondaiy 
implantation with decalcified bone-chips can be done successfully as soon 



544 PRINCIPLES OF SURGERY. 

as suppuration has ceased, and the cavity can be made thoroughly 
aseptic. 

(b) Excision of Portion of Shaft. — This operation is only indicated 
in some cases of diffuse tubercular osteomyelitis where amputation is 
considered unnecessary. Resection of the entire thickness of the shaft 
of a long bone for tuberculosis should be limited to the radius, ulna, 
fibula, tibia, and the metacarpal bones. Extirpation of the entire bone 
affected is frequently necessary in tuberculosis of the wrist- and ankle- 
joints. 

(c) Amputation. — Amputation is often the only choice in the treat- 
ment of diffuse tubercular osteomjelitis, as it offers the 011I3- chance to 
effect complete eradication of the disease, and to protect the patient 
against general infection. It is contra-indicated in the other forms of 
osteotuberculosis, unless complicated by tuberculosis of an adjacent 
joint, and even in such instances it is limited to cases that have passed 
beyond the reach of a typical or atypical resection. 

TUBERCULOSIS OF JOINTS. 

Tuberculosis of joints, chronic fungous arthritis, strumous arthritis, 
and tumor albus are terms that even now are being used synonymously 
to indicate a form of inflammation of joints which clinically is char- 
acterized by its chronic course and the absence of acute signs of inflam- 
mation. This affection is by far the most common joint disease, so much 
so that Konig states that in surgical clinics the surgeon will have 100 
cases of tuberculosis of the joints to deal with to one of the other classes 
of inflammation, such as gonorrhceal, S3 T philitic, suppurative, osteomye- 
litic, rheumatic, or the metastatic inflammations subsequent to acute 
infectious diseases. 

Etiology. — We distinguish, as to origin, between primary synovial 
and primary osteal tuberculosis of the joints. If the primary focus is 
in the bone the disease usually extends to the joint by direct extension 
of the process to the structure of the joint. In primary synovial tuber- 
culosis the bacillus is conveyed through the circulation, and localization 
takes place in the synovial membrane. 

Max Schiiller proved experimentally, in animals infected with tubercle 
bacilli, — for instance, through the respiratory tract, — that a slight trau- 
matism to a joint would determine localization, by wa}' of the circula- 
tion, to the injured part, and that a tubercular synovitis or panarthritis 
would follow. The same author makes the statement, based on the 
results of his experiments, that a slight injury to a joint in a person who 
has bacilli floating in his blood would determine localization, commonly 
in the form of a synovial tuberculosis. Clinically, tuberculosis of joints 



TUBERCULOSIS OF JOINTS. 545 

has been traced in 56 per cent, of the cases to traumatism by a direct- 
blow to a joint, or distortion, or overexertion. It is characteristic that 
the traumatism is always slight ; a severe injury, causing intra-articular 
fracture, is very rarely followed by tuberculosis, for the same reasons 
that severe injuries do not produce the disease in bone and other organs. 
It may be stated that, as to the relative frequency of the two forms of 
infection, it has been shown that primary osteal tuberculosis occurs two 
or three times as often as the primary S3 T novial. Tuberculosis of joints 
is always closely related to the same disease in bone, because, when it 
does not follow the latter as a secondary lesion, the primary synovial not 
seldom implicates the adjacent bone from the direct extension of the 
infection from the fungous synovial membrane to the subjacent bone 
structure. Synovial tuberculosis is more frequent in the adult than in 
children. Primary infection of a joint is possible only through a wound, 
as in the case referred to under the head of Inoculation-Tuberculosis. 
Tubercular infection of an intact joint presupposes the entrance of the 
bacillus of tuberculosis through the respiratory tract or alimentary 
canal, or through some external infection-atrium into the systemic circu- 
lation, or the diffusion of bacilli through the same channel from some 
pre-existing tubercular focus, and the localization of floating bacilli in 
the S} 7 novial membrane by capillary embolism or by mural implantation. 
A simple tubercular nodule over the surface of the synovial membrane 
may lead, in a comparatively short time, to diffuse tuberculosis over the 
entire surface of the joint by local dissemination of the microbes, in 
which the synovial fluid and the movements of the joint play an impor- 
tant part. In the osteal form of tuberculosis of joints the infection 
extends from the bone to the joint at once, in cases where the primary 
disease is the result of infarction, as the base of the wedge-shaped piece 
of the necrosed bone communicates directly with the joint ; while infec- 
tion of the joint occurs secondarily, in cases of granulating foci and 
tubercular necrosis, by perforation of the tubercular product into the 
joint. When the foci are located close to the articular cartilage this 
must be destroyed before the joint is invaded, the cartilage forming a 
barrier that may sometimes prove sufficient to resist invasion. In case 
a focus is located at the surface of a joint, where the bone is not covered 
with articular cartilage, the thin periosteum and the synovial membrane 
covering it are more easily perforated, and consequently secondary syn- 
ovial tuberculosis is more liable to follow. The most complicating con- 
dition may arise if a tubercular focus is located at the insertion of the 
capsule of a joint. It may then open into and outside of the joint 
simultaneously, or the one or the other, the integrity of the joint de- 
pending on the few lines of space occupied by the capsule. 

35 



546 



PRINCIPLES OF SURGERY. 



Pathology and Morbid Anatomy. — In synovial tuberculosis a series 
of pathological changes are initiated in which all the structures of the 
joint are finally concerned, namely, the synovial membrane, parasynovial 
tissues, articular cartilage, and lastly the bone. The tubercle nodule in 
the synovial membrane presents, under the microscope, the same histo- 
logical structure as in other tissues. When the synovial surface has 
become the seat of diffuse tuberculosis the tissues undergo the same 
pathological changes as during the first stage of tuberculosis in other 
organs, and it is the characteristic granulation tissue that has given to 
this form of arthritis the names of fungous synovitis and synovitis hyper- 
plasia granulosa. During the earl} 7 stages of the disease the surgeon 
meets with two distinct varieties; in one the tubercular infection pro- 




Fig. 162.— Tuberculosis of Lower Epiphysis of Femur, with Two Sequestra (a) 
and Perforation into Knee-Joint. (Weber.) 



duces a pulpy condition of the entire synovial sac, with little or no effu- 
sion into the joint, the swelling being due entirely to the presence of 
a thick layer of granulation tissue, — the true tumor aJbus of the old 
writers. This form of tuberculosis gives rise, at an early stage, to exten- 
sive deformity of the joint, flexion, rotation, and, in the case of the 
knee-joint, partial dislocation of the tibia backward. In the other variety 
the fungous granulations are less marked, but a copious effusion takes 
place into the joint, which simulates a catarrhal S}movitis, until time 
and the effect of treatment enable the surgeon to make a correct differ- 
ential diagnosis. In this form Konig assures us that he has never 
observed a tendency to flexion or any other form of displacement of the 
joint-surfaces. If suppuration take place, which is not very often the 
case, it begins in the granulations which cover the S} r novial membrane, 



TUBERCULOSIS OF JOINTS. 547 

and the pus accumulates in the cavity of the joint until perforation of 
the capsule takes place. During the suppurating process the granu- 
lations are destined and the tubercular infection penetrates deeper, 
and, as during the destructive process blood-vessels are destrojed, the 
patient is exposed to the additional risks of general infection. If a 
tubercular joint open spontaneously, or is incised without observing 
strict antiseptic precautions, the additional infection from without leads 
to the most serious consequences, as under these circumstances pus- 
microbes are brought in contact with a surface that has been admirably 
prepared by the bacillus of tuberculosis for suppurative and septic 
processes. 

Pathological Varieties of Joint Tuberculosis.— Tubercular inflamma- 
tion of the synovial membrane of joints results in different gross 
pathological conditions that serve as a basis for classification into: 1. 
Pannous hyperplastic synovitis. 2. Tuberous hyperplastic synovitis or 
papillomatous plastic synovitis. 3. Granular or fungous hyperplastic 
synovitis. 4. Tubercular articular empyema. 

1. Pannous Hyperplastic Synovitis. — The tubercle nodules are ex- 
tremely small, rarely visible to the naked eye, and widely disseminated 
over the entire or greater portion of the synovial sac. The synovial 
membrane is only moderately thickened, but quite vascular. From the 
border of the cartilage a thin, vascular layer of granulations approaches 
the centre of the surface of the joint somewhat in the manner a pannus 
invades the cornea. This form of s3'novitis was first described by Hueter. 

2. Tubercular Plastic Synovitis op Papillomatous Plastic Synovitis. — 
The tubercular inflammation results in the formation of subsynovial 
fibrous masses, which may attain the size of a walnut, protruding into 
the joint and filling, for example, the supra-patellar recess of the knee- 
joint, with simple irritative synovitis or pannous synovitis in the rest 
of the cavity. The tubercular infection in such cases is limited, and the 
removal of the fibrous swelling results in a permanent cure. In other 
cases of the same type of inflammation the foci are numerous, resulting 
in papillomatous plastic synovitis, where the whole inner surface of the 
synovial membrane is covered with sessile or pedunculated papillomatous 
growths, small and rather uniform in size, some of which may become 
detached, when they constitute the so-called rice-bodies. 

3. Granular Fungous Hyperplastic Synovitis. — In this variety of joint 
tuberculosis the synovial membrane is affected throughout, being con- 
siderably thickened and hypersemic, and covered by a more or less thick 
layer of velvety granulations. The ligaments and para-articular struct- 
ures are affected at a comparatively early stage, and thus is formed the 
thick, cedematous mass of tissue, usually of a gelatinous appearance, in 
which here and there cheesy foci are found. 



548 PRINCIPLES OP SURGERY. 

Any of the foregoing forms of tubercular s} 7 novitis may give rise 
to the transudation of serum or a sero-fibrinous fluid into the joint, — 
the tubercular hydrops of Konig. As a rule, the serous effusion is most 
copious in cases where the synovial membrane has undergone the least 
change ; that is, in pannous hyperplastic synovitis. In tuberous and 
papillomatous synovitis the effusion is usually scanty, and in fungous 
synovitis attended by the formation of massive granulations it is absent, 
as a rule. The effusion into the joint, in tubercular hydrops, is either a 
thin, clear synovia, or it is rendered slightly turbid from the admixture 
of leucocytes and the products of coagulation necrosis, or, if the effusion 
is of a sero-fibrinous character, it contains shreds of fibrin. The rice- 
bodies (co?*pora amylaceae), so frequently found in tubercular joints, are 
composed of dense masses of fibrin or they are detached papillomata. 
That these bodies are a tubercular product I have repeatedly satisfied 
myself by inoculation experiments. 

4. Tubercular Articular Empyema {Konig). — The tubercular abscess 
of joints is an advanced stage of the other varieties of tubercular 
synovitis. The inside of the capsule is covered with a loosely adherent 
tuberculous membrane, similar to that in tubercular abscesses. The 
superficial granulations which compose this membrane have undergone 
degenerative changes. Outside of this membrane the tissues are 
diffusely infiltrated with miliaiy tubercles, but the infection does not 
extend be} r ond the synovial membrane. The fluid in the joint, like in 
all tubercular abscesses, is not pus, but serum, in which we find suspended 
the products of coagulation necrosis. With the extension of the tuber- 
cular process be3~ond the limits of the synovial sac, the articular 
cartilage, and, finally, the bone are successively attacked. The articular 
cartilage takes no active part in the inflammatory process ; it is detached 
and removed by the granulations. An osseous focus in contact with 
the cartilage usualty makes a circular defect through which the granu- 
lations or cheesy material can be seen. The cartilage covering a tuber- 
cular infarct is rapidly destro} r ed, and is mechanically detached in 
smaller or larger fragments. In primary tuberculosis of the synovial 
membrane the process usually commences at the periphery of the 
articular cartilage, and from here the granulations dip down into the 
vascular bone, and often undermine the cartilage extensively before any 
destructive changes are witnessed on the side directed toward the joint. 
In such cases the cartilage is not onlj T often extensively detached, but 
perforated at numerous points b} T the granulations underneath it. The 
action of the granulations on the articular extremities of the bone 
produces a condition which has been described for centuries as caries. 
Caries is not a disease, but the result of a disease. The bone becomes 



TUBERCULOSIS OF JOINTS. 549 

softened, and by molecular disintegration, caused by action of the 
granulations, it becomes porous and honey-combed. Numerous miliary 
nodules can be seen in the affected area, which, in the course of time, 
undergo coagulation necrosis and caseation. In long-standing cases the 
destruction of bone is so extensive that in the hip-joint, for instance, it 
may result in the loss of the entire head of the femur and perforation 
of the acetabulum. 

Symptoms and Diagnosis. — The symptoms vary according to the 
/type of the disease and manner of infection. With the exception of 
circumscribed points of tenderness outside of the region of the joint 
that indicate the existence of primary osteotuberculosis, we have no 
symptoms which enable us to make a positive diagnosis between a 
primarv osteal and a primary synovial tuberculosis of a joint. The 
primary osteal form is the most common. In the knee the proportion 
of the primary osteal to the primary synovial form is in the proportion 
of 3 to 1 ; in the hip, 4 to 1 ; in the elbow, 4 to 1. As to age, the propor- 
tion is, in children below 15 years of age, 2 to 1 ; above 15, 3 to 1. In refer- 
ence to the location of the joints affected, it can be said that joint tuber- 
culosis is much more frequent in the lower than in the upper extremities. 
According to Albrecht, out of 325 cases, in 91 the disease affected the 
joints of the upper and in 234 those of the lower extremities. 

I. Swelling. — In the atrophic form of plastic synovitis, the caries 
sicca of Volkmann, so common in the shoulder-joint, there is not only 
no swelling, but the region of the joint may even be found atrophied 
from muscular atrophy. The absence of swelling and the presence of 
considerable mobility in the joint may lead to a wrong diagnosis under 
the impression that the affection is a neurosis. A careful examination 
under the influence of an anaesthetic will, however, reveal restriction of 
mobility from cicatricial contraction of the tubercular capsule, which 
will enable the surgeon to make an early and correct diagnosis. The 
swelling resulting from tubercular hydrops and abscess is caused exclu- 
sive^ by distention of the capsule with fluid, as the capsule in either 
case is but little thickened and the granulations are scant} 7 . In both of 
these conditions the capsule of the joint is often enormousl}* distended. 
In the knee-joint the patella is raised from the condyles of the femur, 
and the depression on each side of it, present in a normal condition in 
the extended position of the limb, is not only effaced, but replaced by a 
well-marked prominence. Fluctuation is distinct. In the dry, fungous 
variety of synovitis the swelling is due to the masses of granulation 
tissue within, and, after perforation of the capsule has occurred, within 
and outside of the joint. This is the most common of all the forms of 
articular tuberculosis. The old authors were of the opinion that the 



550 



PRINCIPLES OF SURGERY. 



oedema in the neighborhood of a white swelling was due to expansion 
or enlargement of the articular extremities of the bones, until Samuel 
Cooper pointed out that it was caused by thickening of the capsule. 
The granulation tissue is often present in such abundance as to give rise 
to considerable distention of the joint, and, in the knee-joint, elevating 
the patella from the condyles of the femur to such an extent that the 
contour of the joint simulates an effusion into that articulation. The 
granulations are so soft that on palpation in these cases fluctuation can 
be distinctly felt, especially if the capsule of the joint is very thin from 
overdistention or destructive changes. To ascertain the character of 






a b c 

Fig. 163.— Knee- Joint. (Albert.) 
A, normal knee-joint; B, tubercular hydrops ; C, tubercular osteomyelitis of internal condyle of femur. 

the contents of such a joint it is usually necessary to resort to an ex- 
ploratory puncture. The invasion of the para-articular tissues causes 
considerable swelling in the region of the joint, imparting to the latter 
the characteristic spindle shape so frequently found in the knee-, elbow-, 
and ankle- joints, the swelling being so much the more conspicuous when 
atrophy of the muscles above and below has taken place. Extension 
of the infiltration from the para-articular tissues in the direction of the 
subcutaneous tissues finally causes the swollen joint to be covered with 
a whitish, immovable, dense skin, giving the joint the appearance from 
which the time-honored name of* white swelling was derived. If a peri- 



TUBERCULOSIS OF JOINTS. 551 

articular abscess appear the swelling of the joint is generally diminished, 
while a new swelling forms in the vicinity or some distance from the 
joint. 

2. Pain. — Pain, as a symptom accompanying tuberculosis of joints, 
although always present, is of extremely variable intensity. In some 
cases it is so slight that patients will continue to use joints distended 
with masses of fungous granulations without much suffering, while in 
other instances a limited disease in the joint will cause complete dis- 
abilit}^ and a great deal of suffering. According to my observation, the 
pain is usually more severe in cases where the granulations are scanty 
than when the synovial membrane is the seat of extensive fungosities. 
As a point in differential diagnosis it may be said that in osteal tuber- 
culosis pain is present from the beginning in the bone, and is not much 
aggravated by the joint disease ; while an almost painless primary syno- 
vial tuberculosis is followed by severe pain with nocturnal exacerbations 
as soon as the synovial membrane and articular cartilages have been de- 
stroyed and the bone has been secondarily implicated in the inflammatory 
process. Absence of tenderness away from the joint and its presence 
in the line of the joint would indicate rather a primary synovial tuber- 
culosis than the osteal variety. In primary synovial tuberculosis in the 
hip-joint the pain is located in the joint and the groin; while in the 
osteal form, during the early stage at least, it is usually referred to the 
inner aspect of the knee. < 

3. Deformity. — Contraction, lateral deviations, subluxations, and 
other abnormal positions usually indicate more or less destruction of the 
articular surfaces of the bones and ligaments. These malpositions are 
not seen in articular tubercular hydrops or the milder forms of synovial 
tuberculosis, while we find different degrees of one or more of them 
nearly in every case of advanced fungous synovitis. Watson Cheyne 
has again called attention to the fact that, in chronic inflammation of 
joints, the explanation of Bonnet, that contractions are caused by intra- 
articular pressure, is no longer tenable, as Luecke (Deutsche Zeitschrift 
fur Chirurgie, B. xxi, H. 5) has shown conclusively that in fungous dis- 
ease of joints the flexed position is induced by the irritation due to the 
inflammation, as in that posture the least amount of pain is incurred. 
If the patient now attempt to walk he naturally contracts all the muscles 
so as to avoid any movement which would aggravate the pain. This con- 
tracted state* of the muscles, however, tends still to heighten the degree 
of flexion, as the flexors are naturally and anatomically stronger and 
less easily fatigued than the extensors. Therefore, the longer this flexed 
position has been maintained, the more marked it becomes, as is the case 
in paralysis originating in the nervous centres. Luecke is of the opinion 



552 PRINCIPLES OF SURGERY. 

that in chronic joint-disease the posture of the joint is adopted volun- 
tarily or from expediency so as to facilitate the use of the limb in the 
same manner as scolio-lordosis is adopted to compensate adduction, dis- 
appearing when the patient is confined to bed, as its only purpose is the 
avoidance of limping. The posture is further influenced by the destruc- 
tion of integral parts of the joints; adduction in the hip-joint, for 
instance, is caused by destruction of the acetabulum, as the varus position 
of the knee is due to destructive changes affecting the internal condyle 
of the femur or the inner tuberosity of the tibia. In advanced cases of 
synovial tuberculosis of the knee-joint the joint is flexed, the leg rotated 
outward, and the head of the tibia displaced backward. In the hip-joint 
the disease gives rise to flexion of the thigh upon the pelvis, and first 
eversion, but later inversion, of the limb. After separation of the head 
of the femur, or extensive destruction of the articular end of this bone 
and the acetabulum, the contour of the region of the hip-joint and the 
position of the limb simulate dislocation of the head of the femur upon 
the dorsum of the ilium. Tubercular disease of the elbow-joint gives 
rise to flexion and pronation of the forearm. The clinical importance 
of any of these displacements lies in the fact that they signify a certain 
amount of destruction of the joint-structures, thus often indicating 
surgical interference for the correction of the deformity, as well as the 
removal of the diseased tissue. Remembering the frequency of tuber- 
cular affections of joints, as a rule, there is little difficult}' in their recog- 
nition, if the history, course, and S3'inptoms are carefully studied and 
analyzed. Konig justly remarks that it is well to remember that 
articular tuberculosis, even if the disease affect a large joint, is practi- 
cally a local disease, and has for a long time little or no influence on the 
general health of the patient. Thus, we may find patients presenting 
all the appearances of robust health suffering from articular tuberculosis. 
The tubercular articular hydrops is distinguished from a catarrhal or 
rheumatic s}^novitis with copious effusion bj^ its persistency and tendenc}^ 
to return after aspiration or after active use of the joint. The presence 
of flocculi or rice-bodies in a joint confirm the tubercular nature of the 
affection. A tuberous synovitis, with the formation of a single mass of 
fibrous tissue, sessile or pedunculated, might be mistaken for lipoma 
arborescens or gummata. The diagnosis of the latter will be cleared up 
by a course of antisyphilitic treatment, which should alwa} r s be insti- 
tuted in cases of .doubt. Tubercular joint-abscess is distinguished from 
suppurative, gonorrhoeal, or rheumatic synovitis by the pain being less 
and the absence of all signs of acute inflammation. The local conditions 
in fungous synovitis are so characteristic that they can hardly be 
misinterpreted by a careful observer. The presence or absence of fluid 



TUBERCULOSIS OF JOINTS. 553 

in the joint has often to be determined by an explorator}' puncture. The 
caries sicca of Volkmann, or dry, pannous, hyperplastic synovitis of 
Hueter, especially as found in the shoulder-joint, might be mistaken for 
a neurosis, with atrophy of the muscles covering the joint. The differ- 
ential diagnosis can be made by making the examination while the 
patient is full}' under the influence of an anaesthetic. If the affection is 
a neurosis, motion will be found unimpaired ; if it is tubercular, the 
mobility of the joint will be found lessened b} 7 intra-articular adhesions 
and cicatricial contraction of the capsule of the joint. 

Prognosis. — Tuberculosis of a joint ma} 7 terminate in a spontaneous 
cure in cases in which the intensity of the infection is slight or the 
resistance on the part of the patient is so great that the fungous granu- 
lations do not undergo degenerative changes, but are converted into 
connective tissue. A partial or complete synechia of the cavity of a 
joint is often one of the unavoidable results in such cases, leaving the 
joint in a permanently stiff condition. This endeavor on the part of the 
organism to limit the extension of the disease is often observed in cases 
in which the joint affection occurs in connection with osteal tubercu- 
losis. As soon as perforation of a focus into a joint has occurred a wall 
of granulation tissue is thrown out around the circumscribed area of 
infection, and, under favorable circumstances, a partition of cicatricial 
tissue is formed which isolates the infected from the intact portion of 
the joint. In such instances we have an illustration how the tubercular 
process is retarded, and sometimes permanently arrested, by the trans- 
formation of granulation into connective tissue. For such a favorable 
termination to take place it is necessary that the tubercular virus should 
be attenuated by age or want of a proper nutrient medium, or that the 
pathogenic effect of the bacilli should be neutralized by an adequate 
resistance on the part of the tissues before degenerative changes have 
occurred in the granulation tissue. The course of articular tuberculosis 
is so variable in different cases that it is impossible, during the early 
stages of an attack, to predict anything certain in reference to the 
probable outcome. A spontaneous cure is more likely to take place if 
the patient is young, not anaemic, and, at the same time, well nourished. 
The hygienic surroundings must also be taken into consideration in 
rendering a prognosis. The disease shows greater tendencies to limita- 
tion in children than in persons past the age of puberty. 

Among the different forms of joint tuberculosis the tubercular 
hydrops and caries sicca are the most benign, and in these cases a spon- 
taneous cure is most frequently realized and the same conditions are 
also most amenable to successful surgical treatment. The caries sicca 
may, according to Konig, terminate in a spontaneous cure in two or 



554 PRINCIPLES OF SURGERY. 

three years, with some loss of motion in the joint. It is sometimes dif- 
ficult to ascertain in a given case when the lesion can be considered as 
cured. As the most reliable evidences that such favorable termination 
has taken place must be considered disappearance of swelling, pain, 
tenderness, and restoration of function as far as this can be expected. 
The patient should not be permitted to use the limb until the active 
symptoms of inflammation have disappeared. The danger to life arises 
from the existence of complications, foremost among them being septic 
infection, pulmonary or general tuberculosis, and amyloid degeneration 
of important internal organs. Septic infection is caused either by 
localization of pus-microbes brought to the tubercular focus through the 
circulating blood, or, what is more frequently the case, through an 
infection-atrium, created by a spontaneous opening; through an operation 
wound ; an exploratory puncture ; or, finally, through a fistulous com- 
munication with the joint. Many neglected cases of joint tuberculosis 
die annually of pulmonary or general tuberculosis. Billroth states that 
in sixteen years 21 per cent, of bone and joint tuberculosis were lost in 
this way. Konig, from a table of 117 operations for tuberculosis, found 
that after four years 16 per cent, had died from general tuberculosis. 
If a patient escape death from septic infection after secondary infection 
with pus-microbes, he is liable to succumb several years later to anrvloid 
degeneration of the spleen, the liver, and especially the kidneys, with its 
accompanying anasarca. 

Treatment. — As spontaneous cure in cases of joint tuberculosis is 
more frequently the exception than the rule, and if finally it does take 
place it does so generally after the limb has become so much deformed 
that it has become useless and will require a formidable operation to 
restore partial function, it is evident that timely surgical treatment 
should be adopted to eradicate the disease, preserve function, and, at the 
same time, protect the patient as far as can be done against general 
infection. 

I. Rest. — As in cases of osteotuberculosis, rest is an important ele- 
ment in the treatment of tubercular joints. It is even more important to 
secure rest for an inflamed joint than for an inflamed bone, as the inflam- 
mation is always greatly aggravated by the movements in the joint that 
necessarily take place as long as the joint is used, which does not apply 
with equal force to cases of osteotuberculosis. The best method to fulfill 
this indication is to immobilize the limb in a plaster-of-Paris splint, 
which does not necessarily confine the patient to his room or bed. If 
one of the lower extremities is to be encased in a plaster splint, I am 
in the habit of applying the plaster-of-Paris roller over tight-fitting, knit 
drawers, which protect the skin much better than an ordinary roller 



TUBERCULOSIS OF JOINTS. 555 

bandage. All bony prominences should be protected against pressure 
by careful padding with absorbent cotton. If the hip-joint is the seat 
of inflammation the splint is applied with the limb in the extended po- 
sition, while the patient stands on the sound limb upon a low stool, as in 
this position auto-extension is made by the weight of the suspended limb. 
In such cases the splint must extend from the toes and embrace the 
entire limb, the whole pelvis, and abdomen as far as the umbilicus, and 
the opposite limb as far as the knee-joint. In tuberculosis of the knee- 
joint the splint should extend from the toes to the groin, and, in ankle- 
joint affections, from the toes to the knee-joint. Immobilization is to be 
made with the limb in such a position that in case the joint should be- 
come permanently stiff the limb can be used to greatest advantage. A 
slight degree of flexion in the hip- and knee-joints is to be preferred to a 
perfectly straight position. In inflammation of the shoulder-joint the limb 
makes the necessary counter-extension, and fixation of the joint is secured 
by confining the limb, with the forearm flexed, at right angles to the side 
of the chest, by strips of adhesive plaster or a plaster-of-Paris bandage. 
The hand should be slightly extended in immobilizing the forearm in the 
treatment of tuberculosis of the wrist, while the forearm is flexed at a 
right angle to the arm in tubercular synovitis of the elbow-joint, with the 
hand in position half-way between pronation and supination. Early im- 
mobilization of a tubercular joint not only secures absolute rest for the 
joint, but, at the same time, this treatment prevents, to a great extent, 
subsequent deformities. Treatment by immobilization should be con- 
tinued until all symptoms of inflammation have subsided, or until more 
radical measures become necessaiy. If the arthritis has already resulted 
in contractures the treatment by extension with weight and pulley is in 
place, and should be continued until the limb has been brought in proper 
position for treatment by immobilization. 

2. Aspiration. — In tubercular hydrops the intra-articular effusion is 
often veiy copious, resulting in enormous distention of the capsule of 
the joint, which, if continued for any length of time, must necessarily 
result in great weakening of the joint. Aspiration under these circum- 
stances relieves the distention and places the vessels in the synovial 
membrane in a better condition to perform their function in the subse- 
quent removal of the inflammtory product by absorption. After evacua- 
tion of the contents of the joint the limb should be immobilized and 
rapid re-accnmulation of the fluid prevented by uniform, equable com- 
pression of the joint by strips of adhesive plaster or rubber bandage. 

3. Tapping and Iodoform ization. — In tubercular hydrops and abscess 
of a joint subcutaneous evacuation of the fluid contents, followed by 
iodoformization practiced in the same manner as has been described in 



556 PRINCIPLES OF SURGERY. 

the treatment of tubercular abscess, yields more satisfactory results than 
simple aspiration. In tubercular hydrops irrigation of the joint with a 
3-per-cent. solution of boric acid is only necessary for the removal of 
rice-bodies ; if such are not present, the iodoform mixture ma}' be injected 
at once. Tubercular abscess always requires a preliminary irrigation 
with some mild antiseptic solution, for the purpose of removing detached 
and disintegrated tubercular products before the iodoform mixture is 
injected. Krause, during a period of eighteen months, treated 43 tuber- 
cular joints by means of iodoform injections ; cases were treated by other 
means, and where cure without operation seemed impossible, but in 
which fistulse were not yet formed. The injections were repeated at 
intervals of two or three weeks. Pain was greatly relieved by this 
treatment ; the swelling yielded much more slowly, though in six weeks 
some cases showed a reduction in size and a hardness of the affected 
parts. The abscess-cavities frequently filled again, rapid ly at first, but 
ultimately re-accumulation ceased. In some cases fistulse formed at the 
seat of puncture, which first discharged pus, then serum, but ultimately 
healed entirely. In a fair percentage treated in this way definitive healing 
was obtained. This treatment promises the best results in cases where 
granulation tissue is scanty, and where the inflammatory product has not 
undergone extensive caseation. Its utility is much impaired if suppu- 
ration has taken place in the joint. Billroth opens the joint, evacuates 
its contents through the incision, removes (if present) tubercular 
sequestra, rice-bodies, and tubercular membranes, and then treats the 
joint by iodoformization. In general practice, however, it is much 
safer to follow the subcutaneous method by puncturing the joint with a 
medium-sized trocar, using the canula for evacuation, irrigation, and 
iodoformization, — the treatment of tubercular joints by arthrotomy, 
curettage, and iodoformization. 

4. Arthrectomy. — Excision of the infected tissues in primary tuber- 
culosis of the synovial membrane has been practiced for a number of 
years, and the results of this treatment have been quite encouraging. 
Primary synovial tuberculosis, without an}' foci in the articular ends of 
the bones, should be treated by arthrectomy and not by resection, as by 
the former operation the diseased tissues can be removed effectually 
without unnecessary loss of healthy tissues that are sacrificed by the latter 
operation. The success of an operation for tubercular affections depends 
largely upon the thoroughness with which the operation is done and the 
absence of suppuration. Arthrectomy should be performed before 
fistulous openings have formed, and the joint must be opened by an 
incision that will expose every nook and corner of the capsule. Of the 
many incisions that have been devised for opening the knee-joint, the 



TUBERCULOSIS OF JOINTS. 557 

one I shall describe here offers the greatest advantages and is open to 
the least objections. The old-fashioned horseshoe incision, with the 
convexity directed downward, makes it very difficult to suture the wound, 
and leaves a scar where it is most exposed to injury. The incision 
carried directly across the knee-joint, if the patella is divided at the same 
time, leaves, subsequently, the superficial and deep parts of the wound 
directly opposite; if the patella is preserved, the scar of the external 
incision falls upon the most prominent part of the patella, which is again 
a great disadvantage. The incision which for several years I have 
always selected in opening the knee-joint in performing arthrectomy or 
resection is Halm's incision, which is slightly curved, but with the con- 
vexity directed upwa?*d. It is carried from the most dependent portion 
of the knee-joint, at a point corresponding to the most prominent 
part of the internal condyle of the femur, in a gentle curve to an inch 




Fig. 164.— Hahn's Incision for Arthrectomy or Resection of the Knee-Joint. 

above the upper border of the patella, and from here downward and 
outward to a point opposite where it was commenced. The short, 
semilunar, cutaneous flap is now detached and turned downward. After 
this an incision is carried directly across the joint, dividing the lateral 
ligaments and crossing the patella transverse^ at its centre. The 
patella, at this step of the operation, is divided with a saw. The 
upper recesses of the synovial sac are freety opened by making an 
incision on each side of the upper half of the patella, which is carried 
as far as the upper recess of the synovial sac. The rectangular flap, 
composed of the upper end of the patella with its muscular attachments, 
is reflected, which exposes every portion of the upper part of the syno- 
vial recess. A somewhat similar flap is made of the lower half of 
the patella and its tendon, reflected in a downward direction, by which 
the tissues underneath that portion of the patella and its ligament are 
fully exposed. . With the knee-joint thus exposed it is not difficult to 



558 PRINCIPLES OF SURGERY. 

extirpate, with the help of a catch-forceps, a sharp scalpel, and a pair of 
curved scissors, the entire capsule. The part of the capsule that will be 
found most difficult to remove is that portion which covers the popliteal 
vessels and dips down behind the cond3des of the femur and behind the 
tuberosities of the tibia. During this part of the operation the leg must 
be forcibly flexed over a small cushion, or the fist of an assistant, in the 
popliteal space. Arthrectomy is always a tedious operation, as it is 
absolutely necessary to remove all of the infected tissues in order to 
secure permanent success. If the patella is not diseased it should never 
be removed. After the capsule has been extirpated the patella is united 
by two chromicized catgut sutures. I have never failed in obtaining 
bony union in four to six weeks after this method of coaptation. After 
extirpation of the capsule, and before the elastic constrictor is removed, 
the whole surface should be once more irrigated with a hot, aqueous 
solution of iodine, after which it is rubbed off with dry iodoform 
gauze, in order to remove any detached fragments that have not been 
washed away. The whole surface is now freely sprinkled with impalp- 
able iodoform, which is rubbed into the surface. Before the constrictor 
is removed the wound is packed with aseptic gauze, the flaps are laid 
over it, and manual compression made for five to ten minutes after 
the removal of the constrictor, with the limb in an elevated position. 
This simple procedure serves an admirable purpose in controlling capil- 
lary haemorrhage, and reduces the necessity of recourse to ligature to a 
minimum. 

After all the bleeding has been arrested the patella is sutured, and 
the deep parts of the wound are united by buried sutures. Tubular 
drainage can usually be dispensed with, as a capillary drain composed 
of a few threads of catgut will answer an excellent purpose, and will not, 
like the tubular drain, necessitate an early change of dressing. The 
external incision is closed with silk-worm-gut sutures, the line of suturing 
being out of the way of the patella, the parts united with the buried 
sutures being covered throughout by the external flap. A careful haemo- 
stasis and rigid antiseptic precautions will make it unnecessary to change 
the dressing earlier than the end of the second week, and on this account 
I prefer to immobilize the limb in a plaster-of-Paris splint applied over a 
copious antiseptic dressing. The limb must be kept in an elevated 
position for at least six hours after the operation, so as to diminish the 
amount of parenchymatous haemorrhage. If all the infected tissues have 
been removed and the wound remain in an aseptic condition, the external 
wound will be found closed in the course of two or three weeks. A fair 
restoration of function with partial mobility of the joint can be expected 
in favorable cases. Passive motion must be delayed until the patella has 



TUBERCULOSIS OF JOINTS. 



559 



firmly united, which will require from three to four weeks in children and 
nearly twice this length of time in adults. After the patella has united 
and the external wound is completely healed, recovery is hastened by 
passive motion, massage, and use of the faradic current. Arthrectou^ 
has a promising future in the treatment of primary synovial tuberculosis 
of the knee-joint, but for well-known anatomical reasons it is not equally 
applicable in the treatment of synovial tuberculosis of any other of the 
larger joints. It is possible that the operation will be modified and suf- 
ficiently perfected in the future so as to be applicable in the treatment of 
synovial tuberculosis of the hip- and shoulder- joints. In a number of 
cases of tuberculosis of the elbow-joint I obtained an excellent result 
from arthrectomy combined with temporary resection of the olecranon 
process. This process was divided obliquely with a saw at its junction 
with the»shaft of the ulna, and, after the extirpation of all of the infected 
soft tissues of the joint, the process was fastened in its proper place with 




Fig. 165.— Interrupted Plaster-of-Paris Splint for Resection of the Knee-Join t. 



an aseptic ivory nail or chromicized catgut sutures. The functional 
result was satisfactory. 

5. Atypical Resection. — The incision in atypical and t} 7 pical resec- 
tion of the knee-joint should be the same as has been described above. 
The patella is divided transversely, and if it does not contain a tuber- 
cular focus it is not necessaiy or advisable to remove it, as its conti- 
nuity after resection can be restored by suturing with a durable form 
of catgut. An atypical resection consists in the removal of tubercular 
foci in the epiphyseal extremities of the bones that enter into the forma- 
tion of the joint, without removing the entire articular extremities by 
a transverse section with the saw. The unnecessary removal of the 
epiphyseal extremities should especially be avoided in the case of chil- 
dren, as the removal of one or both centres of growth of bone will 
result in so much shortening of the limb subsequently as often to render 
it not only perfectly useless, but it becomes a burdensome appendage. 



560 PRINCIPLES OF SURGERY. 

In children at3^pical resection should be practiced in all cases where all 
the foci in the articular extremities can be reached and removed by this 
method. The proper instruments to be used in this operation are the 
chisel, bone-forceps, and sharp spoon. After the joint has been freely 
opened, the articular surfaces are carefully inspected for evidences of 
deep-seated foci. If perforation into the joint has taken place the 
cavit}' is freely exposed from the articular surface, and all of the infected 
tissues are removed with chisel and sharp spoon. It is important not 
only to remove necrosed bone, granulation tissue, and caseous material, 
but also the surrounding osteoporotic zone of bone that possibty might 
contain tubercle bacilli. A deep-seated focus may be suspected and 
should be searched for if the articular cartilage has become detached 
over a greater or less extent. Explorations with a small perforator can 
be made in different directions from the articular surface in searching for 
deep-seated foci. If the articular cartilage has become detached over 
a considerable area by granulations underneath it, it should be removed, 
and the exposed bone must be subjected to another careful examination 
for the purpose of locating and treating deep-seated foci. A circum- 
scribed area of great vascularity is a suspicious indication and calls for 
a limited excavation with a small, sharp spoon for diagnostic purposes. 
It is well for the surgeon to remember that primar} r osteotuberculosis 
with secondary involvement of a joint usually consists of more than one 
focus in one or both epiphyseal extremities. A tubercular infarct is 
generally recognized by examining the articular surface, as the cartilage 
or the exposed portion of the wedge-shaped sequestrum presents appear- 
ances of necrosis that cannot be mistaken. After the extraction of the 
sequestrum the tubercular cavity is submitted to the same treatment as 
when dealing with a granulating or caseous focus. In primary synovial 
tuberculosis, with extension of the disease to the subjacent bone, it be- 
comes necessary to remove the honey-combed, softened bone over the 
entire surface with the sharp spoon and chisel. Before the operation is 
extended to the bone in osteotuberculosis it is always necessary first to 
extirpate with knife and scissors the infected soft structures of the joint, 
the synovial membrane, and ligaments, as otherwise the healthy vascular 
bone may become an infection-atrium for traumatic infection, — a not 
very infrequent and serious complication after operations on bones and 
joints for tubercular affections. 

Wartmann, after giving a careful account of the results following- 
excision of tubercular joints in the hospital practice of Feurer, gives the 
statistics of 837 cases of excision of joints for tuberculosis from the 
practice of different operators. Of this number 225 died. Of the fatal 
cases, in 26 death followed the operations closely, and resulted from 



TUBERCULOSIS OF JOINTS. 561 

acute tuberculosis, probably induced by the operation. Konig observed 
16 cases in his own practice in which miliary tuberculosis followed 
almost immediately after operations on bones and joints for tubercular 
affections. Konig states that the secondary or re-infection sets in seven 
to ten days after operation, which may have been perfectly aseptic, with 
healing of the wound by primary union. The secondary tubercular 
infection appears either as an acute general miliary or pulmonary tuber- 
culosis, or tubercular meningitis, terminating in death three or four 
weeks after the operation. It is not difficult to conceive the modus 
operandi of such an occurrence. The resection wound opens numerous 
veins in the bone the lumina of which remain patent, ready for the intro- 
duction of minute fragments of granulation tissue or bacilli, which, on 
entering the venous circulation, are the direct cause of metastatic tuber- 
culosis in distant organs. We must take it for granted in such cases 
that a tubercular focus, during the operation, furnished the essential 
infected fragments of granulation tissue, or free bacilli are aspirated or 
forced into the openings of wounded vessels, and through them gain 
entrance into the general circulation. To guard against such an accident 
it is necessary to remove from the joint all possible sources of infection 
before operating on the articular extremities. Cartilage that remains 
firmly attached to the bone may be left. After all foci have been 
radically eliminated, the field of operation is flushed with an antiseptic 
solution, and, after drying and iodoformization, the bone-cavities are 
packed with antiseptic decalcified bone-chips, and the operation is com- 
pleted in the same manner as in arthrectomy. 

The treatment of bone-cavities with decalcified bone-packing is of 
the greatest utility in atypical resection. An atypical resection with 
subsequent implantation of decalcified bone has for its objects complete 
removal of the infected tissues in the joint and the surrounding bone, 
and the partial restoration of the parts destro} r ed by disease or removed 
during the operation. In atypical resection of the knee-joint it is not 
uncommon that nearly an entire condyle of the femur or tuberosity of 
the tibia must be remoA r ecl. In such cases the surgeon aims at bony 
union between the articular ends of the bones, which is accomplished in 
the most satisfactory manner by placing the parts in a condition to 
repair the lost bone-tissue, which may be done by filling the defect with 
decalcified bone-chips. I have repeatedly made excavations in one of 
the condyles of the femur and in the head of the tibia from the joint 
surface, the size of a small orange, and obtained bony ankylosis, with 
the limb in a good position, by filling the cavities with bone-chips. As 
the bone-chips are always iodoformized before implantation, they serve a 
useful purpose not only by furnishing a temporary scaffolding for the 

36 



562 PRINCIPLES OF SURGERY. 

reparative material, but they constitute a valuable therapeutic measure 
in the prevention of a local recurrence of the disease in case tubercle 
bacilli should remain in the cavity or its immediate vicinity. Immobili- 
zation of the limb after resection should be continued until the process 
of repair has been completed, which, under the most favorable con- 
ditions, requires from six weeks to two months. Atj^pical resections are 
applicable only to certain joints, as the knee-, elbow-, ankle-, carpal, and 
tarsal joints. The elbow-joint is most accessible through a long, straight, 
posterior incision, and after temporary resection of the olecranon process. 
At} T pical resection of the ankle-joint can be done through two lateral 
incisions, after temporary resection of the malleoli, with chisel and sharp 
spoon. In all resections, atypical and typical, ignipuncture is indicated 
after the excision has been completed, if any portion of the bone is ab- 
normally osteoporotic, as this procedure will stimulate the process of 
repair, and may prove useful in destroying infected tissues, which, from 
their macroscopical appearance, indicate a healthy condition. 

6. Typical Resection. — In typical resection one or both articular 
extremities are sawn across and removed. In the hip-joint it implies 
the excision of the head, neck, and part or the whole of the greater 
trochanter of the femur. A typical resection of the wrist-joint means 
the removal of the entire carpus, with or without the articular surfaces 
of the radius, ulna, and metacarpal bones. In a typical resection of the 
shoulder-joint the head of the humerus is removed. In the knee-joint 
the operation means excision of the articular surfaces of the femur and 
tibia; in the elbow-joint, of the humerus, radius, and ulna; in the ankle, 
of the tibia, fibula, and astragalus. Typical resections are generally made 
for tubercular affections of the shoulder, hip, and wrist-joint. In the 
remaining large joints it is more frequently resorted to in adults than 
children. In children the operation is limited, with the exception of the 
shoulder-, hip-, and wrist- joints, to cases where the articular extremities 
are so extensively diseased that an atypical resection would fail in re- 
moving all of the infected tissues. Removal of the diseased synovial 
membrane and ligaments should precede section of the bones with the 
saw wherever, from the anatomical construction of the joint, this can be 
done. In the hip- and shoulder- joints the head of the bone must be re- 
moved first before the soft structures of the joint can be extirpated. The 
operation best adapted for resection of the hip-joint is the one devised 
by Konig, by which the borders of the trochanter major are preserved. 
In this operation the section of the bone must be made with a chisel. 
The entire neck and head of the femur are removed by dividing the 
bone transversely with a chisel just below the neck, with the exception 
of the borders of the greater trochanter, which are split off with the 



TUBERCULOSIS OF JOINTS. 563 

same instrument. The capsular ligament is removed as thoroughly as 
possible, and the acetabulum is scraped out with a sharp spoon. Pro- 
vision for drainage must be made in all hip-joint resections. During the 
last four years the writer has substituted with advantage temporary re- 
section of the trochanter major for Konig's operation. After the com- 
pletion of the resection the trochanter is sutured to the shaft of the bone 
with two or more chromicized catgut sutures. The after-treatment con- 
sists of rest in bed upon a smooth mattress, with the limb extended by 
weight and pulley in an abducted position. After six weeks the patient 
is allowed to walk on crutches, with a raised sole under the shoe, worn 
on the opposite side, so that the limb on the resected side makes the 
necessary auto-extension. During the night extension is applied for 
eight months or a year, in order to prevent unnecessary shortening. 
E version and inversion of the limb while the patient is in bed are pre- 
vented either by a Yolkmann railway-splint or by supporting the limb 
with sand-bags, applied to each side. Immobilization, after resection of 
the shoulder-, elbow-, wrist-, knee-, and ankle-joints, is best secured in a 
plaster-of-Paris dressing, which also serves an excellent purpose in keep- 
ing the antiseptic dressing in situ. 

Temporary resection of the olecranon process in excision of the 
elbow-joint has yielded excellent results in my hands, as by it the inser- 
tion of the biceps muscle is not disturbed. The resected olecranon, after 
the removal of any foci it may contain, is riveted to a denuded surface 
of the shaft of the ulna with a sterilized ivory or bone nail or chromi- 
cized catgut sutures, after the resection has been completed. The fore- 
arm is immobilized in a semiflexed position until bony union between the 
shaft of the ulna and olecranon process has taken place, which usually 
requires about six weeks. After this time passive motion and massage 
should be made to increase the mobility of the joint. A straight, single 
incision upon the dorsal side is best adapted for resection of the wrist- 
joint, as the extensor tendons of the hand and fingers can be drawn aside 
sufficiently to afford ample room for the removal of the entire carpus. 
In the after-treatment of excision of the wrist the forearm and hand as 
far as the metacarpophalangeal joints are encased in a plaster-of-Paris 
splint, with the hand in a slightly-extended position. Immediate fixation 
of the resected ends by means of bone or ivory nails, after excision of 
the knee, is superfluous, as the parts can be kept in accurate position by 
ordinary fixation dressing. In knee-joint resections the section through 
the bones must be made in such a manner that when the sawn surfaces 
are brought in apposition the leg will be slightly flexed, as this position 
enables the patient to walk more gracefully than with a straight, stiff 
limb. The artificial support must not be removed until firm bony union 



564 PRINCIPLES OF SURGERY. 

has taken place, which will require from two to three months, according 
to the patient's general health and age. 

7. Amputation. — Amputation must be reserved for cases presenting 
special indications. It is the only operation that promises any benefit 
if the patient suffer at the same time from tuberculosis of other organs, 
provided the general conditions furnish no positive contra-indications. 
It is also indicated if a tubercular abscess has perforated the capsule of 
a joint and has extensively infiltrated the surrounding tissues. This 
condition is to be expected if the limb has become cedematous some 
distance from the joint. The flaps must be taken from the side of the 
limb where the skin is in the best condition, and the incision through the 
deeper tissues must be made through healthy tissue. It is astonishing 
how rapidly wounds heal, and how quickly patients will recover after 
amputations for extensive local tubercular processes, even in patients 
greatly emaciated by the disease. 



CHAPTER XXII. 

Tuberculosis of Tendon-Sheaths, etc. 
tubercular tendo-vaginitis. 

Tuberculosis of the tendon-sheaths, or, as Hueter termed this affec- 
tion, tendo-vaginitis granulosa, has been only quite recentty recognized 
and described as a primary local tuberculosis. 

Pathology. — Hueter was of the opinion that this affection is seldom 
met with as a primary lesion, but that it appears usually as a complica- 
tion of joint tuberculosis. As a secondary lesion it is a frequent con- 
comitant of osteal and synovial tuberculosis by direct extension of the 
inflammation from the primary focus to tendon-sheaths. Volkmann gave 
an able and accurate description of tendon-sheath tuberculosis in 1875, 
but at that time he was not aware of its tubercular nature. The first 
scientific treatise on this affection came from the clinic at Gottingen by 
Riedel, who showed that the rice-bodies so commonty found in the so- 
called fibrinous hydrops of the tendon-sheaths, or hygroma of the flexor 
tendons of the hand, always indicated a synovial tuberculosis. Another 
important paper on the same subject was published by Beger, who re- 
ports 4 cases that occurred in the clinic at Leipzig. The chronic tendo- 
vaginitis, or compound ganglia of the old authors, has been shown to be, 
on careful clinical observation, microscopic examination, and bacterio- 
logical research, cases of local tuberculosis. The extension of tubercular 
processes along tendon-sheaths from a tubercular joint after perforation 
of the capsule has, for a long time, been known to occur, but as a 
primary lesion it has onty recently been added to the long list of surgical 
lesions of a tubercular character. As compared with other tubercular 
affections, primary tendon-sheath tuberculosis is quite rare, as it consti- 
tutes only 1 or 2 per cent, of the cases in the statistics of local tubercu- 
lar lesions. When this affection occurs primarily and independently of 
tuberculosis of an adjacent bone or joint, infection with the bacillus of 
tuberculosis takes place by localization of floating microbes in some 
small vessel, and subsequently the pathological processes in the tendon- 
sheaths resemble those of tubercular joints. In some cases the products 
of the disease are massive granulations that occup3 r the inner surface 
of the tendon-sheaths ; in others the granulations are less abundant, but 

(565) 



566 PRINCIPLES OF SURGERY. 

a copious synovial exudation is thrown out ; while in a third class the 
granulations form hard, white masses, the so-called corpora oryzoidea, 
which either remain attached to the inner surface of the sheath, or, 
after their separation, are found as loose bodies. In the form of tendo- 
vaginitis which corresponds with the fungous variety of tubercular 
synovitis, the granulations form a layer of from 1 to 4 lines in thickness 
upon the inner surface of the sheath. The tendon itself is covered with 
a somewhat thinner layer of granulation tissue, the granulations pene- 
trating the substance of the tendon between the bundles of connective- 
tissue fibres, where, by absorption and pressure atrophy, they cause 
extensive destruction of tissue. In this manner the tendon becomes so 
much weakened that it ruptures on the slightest traction, or, if the dis- 
ease has progressed still farther, the loss of continuity becomes complete 
without a trauma. The intrinsic tendency of the disease consists in 
progressive extension by continuity of structure along the course of the 
tendon primarily affected, and when this tendon is part of a compound 
tendon the disease gradually creeps from tendon to tendon until all the 
sheaths are involved. As this affection is met with most frequently in 
the tendon-sheaths surrounding the carpus, and as these sheaths are not 
infrequently in direct communication with the wrist-joint by means of 
small synovial sacs, it extends to the joint by continuity of surface. 
When no such direct connection exists between the tendon-sheath and 
the subjacent joint, the joint may become secondarily involved after the 
granulations have perforated the capsule. Next to the region of the 
wrist-joint the tendo Achillis, the patellar, and other tendons about the 
knee-joint are most frequently affected, In tuberculosis of the sheaths 
of the tendons of the deep flexors of the fingers the swelling is often 
large, extending from the lower portion of the palm of the hand under- 
neath the annular ligament to the middle of the forearm. Underneath 
the annular ligament the swelling is constricted by this structure, which 
gives rise to considerable bulging in the palm of the hand and over the 
lower anterior aspect of the forearm. The fluctuating wave can be dis- 
tinctly felt above and below the annular ligament, showing that the two 
swellings are in direct communication. The tubercular product under- 
goes the same pathological regressive, changes as in synovial tuberculosis. 
If a sufficient number of tubercle bacilli is present in the granulation 
tissue the cells are destroyed by coagulation necrosis and caseation, 
the fungous masses breaking down into an amorphous, granular detritus. 
At this stage perforation of the tendon-sheath may take place in an out- 
ward direction, and a subcutaneous tubercular abscess develops. If such 
abscess open spontaneously, or is incised without regard to antiseptic 
precautions, infection with pus-microbes will lead to acute suppurative 






TUBERCULAR TENDOVAGINITIS. 567 

inflammation, which will often result disastrously from rapid extension 
of the phlegmonous inflammation and septic infection. The occurrence 
of rice-bodies in tendon-sheath and synovial tuberculosis can be traced 
to a specific action of the bacillus of tuberculosis on the tissues. Konig 
attributes to this bacillus properties which place it among the agents 
that produce fibrinous inflammation. The rice-bodies in the tendon- 
sheaths, the seat of a chronic inflammation, he considers as the product 
of a fibrinous inflammation caused by the action of the bacillus of tuber- 
culosis. Nicaise, Poulet, and Villard examined 4 cases of hygroma con- 
taining rice-bodies, and found in all of them the bacillus of tuberculosis. 

Symptoms and Diagnosis. — Tuberculosis of the tendon-sheaths is an 
exceedingly chronic affection. The disease is not painful, and patients 
often continue to follow their occupation after a number of tendons have 
become involved and the swelling has reached considerable dimensions. 
The swelling increases in length in the direction of the tendon first 
affected, and if the disease extend to neighboring sheaths it branches 
out in the direction of the tendons affected. In 9 out of 10 cases it 
attacks a flexor or extensor tendon in the region of the wrist-joint, and 
then extends upward and downward in the direction of the tendons. In 
tubercular hydrops of the tendon-sheaths the swelling often attains great 
size. In one such case I found the palm of the hand the seat of a 
swelling, the size of a large orange, that communicated with a smaller 
swelling above the annular ligament of the wrist-joint. In the fungous 
variety the swelling imparts to the palpating finger a semi-elastic resist- 
ance, and fluctuation is either entirely absent or not well marked. The 
disease often extends to the middle of the forearm, and in this locality 
attacks the muscular tissue in the same manner as the tendons farther 
below. Extension to a joint is attended by s} ;r mptoms that point to 
synovial tuberculosis. The symptoms are so characteristic that a correct 
diagnosis can often be made on first sight. The only affections that 
must be excluded are the ordinary ganglion of tendon-sheaths and acute 
plastic tendo-vaginitis. A ganglion always remains as a circumscribed 
swelling without manifesting any tendencies to extend. The contents 
of a ganglion are a gelatinous mass, of the color and consistence of 
clarified honey. After evacuation of the sac no swelling remains, as the 
cyst-wall is not much thickened. A plastic tendo-vaginitis, resulting 
from injury or overexertion, is an acute affection not attended by much 
effusion or inflammatory exudation. The tendon-sheath is abnormally 
dry, giving rise to friction-sounds which can be plainly felt and often 
heard as the tendon moves within the inflamed and roughened sheath. 

Prognosis. — Spontaneous cure is the exception, progressive exten- 
sion the rule. The danger from regional extension arises from the 



568 PRINCIPLES OF SURGERY. 

tendencies of the disease to invade adjacent joints, and to extend from 
tendon to tendon, and finally along these to the respective muscles. 
There is no reason why, occasionally at least, tendon-sheath tuberculosis 
should not be followed by pulmonary or general tuberculosis in conse- 
quence of secondary infection. 

Treatment. — The use of external applications, compression and 
aspiration, are of doubtful utility in the treatment of this affection. 
Tapping, followed by iodoformization, promises more, especially in 
cases of tubercular hydrops with few or no rice-bodies. As the rice- 
bodies contain the essential cause of the disease, it will usually be 
found necessary to remove them in order to effect a permanent cure. 
Removal of these bodies, as well as extirpation of the granulation tissue, 
can only be accomplished by a radical operation. A radical operation 
has for its object the removal of all of the infected tissues, which means 
extirpation of the tendon-sheath and erasion of the granulations that 
have invaded the tendon. No operation should be undertaken unless the 
surgeon can count with almost positive certainty upon aseptic healing 
of the wound. Infection with pus-microbes under such circumstances 
would not only prevent a satisfactory functional result, but would place 
the patient's life in great peril. Fortunately, this form of surgical tuber- 
culosis attacks localities where the surgeon has it in his power to obtain, 
almost with absolute certainty, an aseptic healing of the wound. Extir- 
pation of a tubercular tendon-sheath is a tedious and difficult task. The 
operation must be made with the nicety of a dissection in the anatomical 
room. A large tenotomy knife and a small pair of curved scissors are 
the most useful cutting instruments in making the dissection. A number 
of small tenacula and toothed dissecting forceps are necessary to retract 
tendons and expose the parts fully to view. Esmarch's constrictor is an 
indispensable aid, as it renders the tissues perfectly bloodless, which 
enables the operator to identify the parts concerned in the dissection 
After the antiseptic precautions have been completed with the greatest 
care, the limb is rendered bloodless and the tendon-sheath is fully 
exposed by free external incision, which should reach on both sides a 
little beyond the visible limits of the disease. The tendon-sheath is now 
slit open, and the fluid contents are washed away by an antiseptic 
irrigation. 

In operating upon the flexor tendons of the hand and fingers, it 
often becomes necessary to divide the annular ligament, which can be 
done without fear of impairing the functional result, as, after the opera- 
tion on the tendon has been completed, its continuity can be restored by 
a number of separate buried sutures, The large arteries and nerves are, 
of course, carefully avoided. In order to remove the tendon-sheath 



TUBERCULAR TENDO- VAGINITIS. 569 

completely, it becomes necessary to liberate the tendon and to have it 
drawn out of the way by an assistant. The removal of the deep portion 
of the sheath requires special care, as it often is in close proximity to 
the underlying joint, which should not be opened unless the disease has 
invaded the capsule deeply. The extension of the disease to the mus- 
cular tissue can be readily ascertained from the naked-eye appearances 
of the muscle, which, if affected, presents a grayish appearance, and is 
firmer than in a normal condition. If the tendon is extensively infil- 
trated its size is often much diminished by the removal of the infected 
portion, which must be done with a sharp tenotomy knife. If several 
tendons are affected, and access to the more remote ones is rendered im- 
possible without division of the more superficial tendons, these can be 
divided and again united after the dissection has been completed. I 
have repeatedly spent two hours in an operation for tendon tuberculosis 
in the wrist-joint region, and have always felt that the time was well 
spent, as a hasty operation is often attended by unnecessary injury to 
contiguous parts, and is frequently followed by local recurrence on 
account of incomplete removal of the infected tissue. Should it become 
necessary to resect a portion of a tendon on account of extensive disease 
of this structure, restoration of continuity must be effected by an auto- 
plastic operation. The tendon-end most suitable for this purpose is 
selected. The tendon is cut through one-half at a distance from its cut 
end which corresponds with the length of the defect, when it is split 
toward the cut end to within a few lines, and the piece is then laid over 
the defect and sutured at both ends. After the removal of the infected 
tissues the wound is irrigated once more with an antiseptic solution, 
dried, and iodoformized. The deep fascia is united separately with buried 
sutures, and the skin is coaptated accurately with interrupted stitches 
and the continued suture. A catgut capillary drain is inserted and a 
copious antiseptic dressing applied. The limb is placed upon a well- 
padded splint, and, if no indications for a change of dressing arise, the 
first dressing is allowed to remain from two to three weeks, when the 
wound will be found healed throughout. The functional result is almost 
alwa^ys satisfactor}^ if the wound heals by primary union. Massage and 
passive motion are instituted as soon as the wound is healed. If the 
operation is done early and with the necessary care, a local recurrence is 
not to be expected. For the purpose of illustrating the pathological 
conditions and the clinical tendencies of this disease, I will briefly 
describe one of the many cases of tendon-sheath tuberculosis that have 
come under my observation. This case is remarkable on account of the 
rapid extension of the disease. The patient was a man 60 }^ears of age, 
laborer, and addicted to intemperate habits. I examined him, in consul- 



570 PRINCIPLES OF SURGERY. 

tation with his family physician, about four months before the operation 
was performed. At that time I found an oblong swelling on the dorsum 
of the right hand, corresponding to the location of the extensor tendon 
of the index finger. The swelling was not painful, and but little tender 
on pressure. Fluctuation was well marked ; on deep pressure movable 
bodies could be distinctly felt, which were recognized as corpora ory- 
zoidea. An operation was advised, but was declined, as the patient was 
still able to follow his occupation. The swelling was first noticed six 
weeks before the examination, but steadily increased in size. Four 
months later he was admitted into the Milwaukee Hospital, as the pain 
and the size of the swelling now disabled him from performing manual 
labor. At this time the dorsum of the hand corresponding to the index 
and middle fingers and the radial aspect of the forearm as far as the 
middle presented a continuous swelling, with well-marked fluctuation. 
The swelling had lately become painful, and was tender on pressure. 
Under strict antiseptic precautions the swelling was incised in its entire 
length, and a large quantity of synovia-like fluid and softened rice-bodies 
escaped. The sheaths of the extensor communis digitorum and exten- 
sors of the wrist were found lined with a thick layer of fungous granu- 
lations, and near the annular ligament numerous free and attached rice- 
bodies were found. The tendon-sheaths were carefully dissected out, 
and the whole wound, after thorough disinfection, was dusted with iodo- 
form, drained, and sutured. A copious dressing of iodoform gauze and 
sublimated moss was applied, and the forearm and hand fixed upon an 
anterior splint. Healing of the wound by primary intention. Almost 
complete restoration of function. No return after two years, and patient 
able to perform hard manual labor. Inoculations of the fluid upon 
potato remained sterile. Cultivation upon coagulated hydrocele- serum 
showed, after a few weeks, a scanty culture of the bacillus of tubercu- 
losis. Implantation of one of the rice-bodies into the subcutaneous 
connective tissue of a guinea-pig resulted in a typical tuberculosis, 
starting from the point of inoculation, spreading to adjacent lymphatic 
glands, and finally resulting, in six weeks, in death from diffuse miliary 
tuberculosis. 

TUBERCULOSIS OF MUSCLES. 

This affection was first described by Zenker in 18*70, but in all of the 
cases, 5 in number, published by Oltendorf in 1885, it had extended by 
contiguity from an adjacent organ. Similar cases were observed later by 
Genzmer, Marchand, Rapp, Bidder, and others. Latour saw a case of 
tubercular abscess of the external radial muscles and of the deltoid, and 
Denonvilliers found an isolated tubercular abscess in the biceps muscle. 
Habermaas first described muscle tuberculosis as a primary affection. 



FASCIA TUBERCULOSIS. 571 

Miiller reported a similar case from the clinic at Tubingen. The swelling 
in this case involved the quadriceps muscle. Delorme gave a description 
of four cases of primary tuberculosis of muscles at the fifth meeting of 
the French Congress of Surgeons. J. L. Reverdin observed a case of 
primary tuberculosis of the triceps muscle. The first thorough descrip- 
tion of primary muscle tuberculosis was given by Lanz and Quervain, 
based on the clinical history and microscopical examinations of 8 cases. 
They made careful histological and bacteriological investigations with 
a full description of the diagnosis, prognosis, and treatment of this af- 
fection. The results of their observations appear to prove that this form 
of tuberculosis is amenable to successful treatment by thorough excision. 

FASCIA TUBERCULOSIS. 

The bacillus of tuberculosis has a special predilection for fascia, and 
primary localization in this tissue is a frequent occurrence. It is a well- 
known clinical fact that, as soon as a deep tubercular focus in a lymphatic 
gland, bones, or joints has reached the connective tissue outside of the 
organ primarily affected, the infection travels along the connective 
tissue, often resulting in extensive destruction of this tissue before the 
process reaches the surface. The extension of tubercular abscesses along 
preformed connective-tissue spaces has been previously described. If 
the tubercular product, when it reaches the loose connective tissue, is 
composed of living embryonal tissue, the pathological lesions which are 
later produced in the connective tissue correspond with those of the 
primary lesion. The connective tissue is transformed into masses of 
granulation tissue, which remains in this state for a long time before it is 
destroyed by coagulation necrosis, with subsequent cell disintegration. 
In primary tuberculosis of the fascia the disease often spreads with great 
rapidity, dipping down between the muscles along the intermuscular 
septa, and invading from here the muscles themselves. I have seen a 
number of cases during the last few years where the disease originated 
primarily in the deep fascia of the thigh, resulting in the most extensive 
regional dissemination in the course of two or three years. In one case, 
a veteran of the late war, 55 years of age, the disease commenced at a 
point between the greater trochanter and the crest of the ilium several 
years before he came under my observation. I found the thigh moder- 
ately swollen with several prominences from the crest of the ilium to 
the knee-joint, where fluctuation was quite distinct. I mistrusted a 
primary osteotuberculosis, but, on making free incisions at different 
points, I found no evidence of primary tuberculosis of any other tissue 
or organ. The deep fascia and intermuscular septa were found destroyed, 
and in their place masses of granulation tissue presenting foci of coagu- 



572 PRINCIPLES OF SURGERY. 

lation necrosis and caseation invading extensively the muscular tissue. 
Volkmann's spoon was freety used, but I soon found that this treatment 
was utterly inadequate to remove all the infected tissue, as the deep 
muscles throughout were extensively infiltrated. Amputation was out 
of the question, as the gluteal region as far as the crest of the ilium was 
so extensively affected that it would have been impossible to obtain a 
covering for a hip-joint amputation. Iodoformization of the enormous 
spaces made by scraping out the fungous granulations had no effect in 
arresting further extension of the disease. The patient died, three 
months later, of general miliary tuberculosis. 

In a second somewhat parallel case the disease extended from near 
the knee-joint as far as the trochanter minor. This patient was only 25 
years of age, and the disease had existed a year and a half. Several 
incisions had been made, and a number of fistulous openings were found 
in communications with large cavities between the deep muscles of the 
thigh. The sinuses were laid open and scraped, and the most careful 
examination failed in disclosing a primary osteal or tendon-sheath tuber- 
culosis. The muscles were again found extensively infiltrated and of a 
grayish-white color, and almost of gristly hardness on being incised. 
The operation rather hastened than retarded the progress of the disease, 
and I was forced, a few weeks later, to amputate the thigh just below the 
trochanters. The patient made a slow recovery, but at the present time, 
two years after the operation, he is in fair health, and there is nothing to 
point to a local recurrence. I have learned to regard fascia tuberculosis 
affecting the intermuscular septa of the thigh as an exceedingly grave 
form of local tuberculosis, and, if at all extensive, only amenable to 
successful treatment by amputation. 

TUBERCULOSIS OF MOUTH AND TONGUE. 

We have now every reason to believe that many cases of ulceration 
of the tongue, pharynx, and cavity of the mouth, which have been here- 
tofore diagnosticated and treated as carcinoma, were not carcinoma, but 
syphilis or tuberculosis. Professor von Esmarch, in a very able paper, 
a few years ago called attention to the difficulties in the way in differ- 
entiating between these affections. Out of 114 cases of buccal tuber- 
culosis collected by Delavan, in 1886, only two were on the lip. Mac- 
kenzie, of Edinburgh, refers to a third ; a fourth was seen in Vienna, but 
not reported ; and Welch, of Baltimore, had met with a fifth. There can 
be but little doubt that many similar cases have been mistaken for 
carcinoma. 

Pathology. — There is no doubt that many reported cases of perma- 
nent recovery, after removal by operation of ulcerating swellings of the 



TUBERCULOSIS OF MOUTH AND TONGUE. 573 

tongue, were not cases of carcinoma, but tuberculosis. Lupus of the 
pharynx and tongue are cases of local tuberculosis. Some time ago 
I had an opportunity to examine a case of primary tuberculosis of the 
pharyux occurring in a man 30 years of age. The disease had ex- 
isted for four months, and involved the posterior wall of the pharynx, 
and had extended to the left tonsil. Ragged, deep ulcers had formed, 
which were covered with flabby, yellowish-gray granulations. Numerous 
minute miliary nodules could be seen in the mucous membrane around 
the ulcers, and on scraping away the granulations they were also found 
present in the softened, inflamed tissues underneath the floor of the 
ulcers. A beginning hoarseness indicated that the disease was extend- 
ing by continuity of tissue to the larynx. Laryngoscopical examination 
revealed numerous minute nodules, which studded the mucous membrane 
of the posterior surface of the epiglottis. The recent advances made 
in the microscopical, bacteriological, and experimental methods of ex- 
amination have succeeded in separating from s}qDhilitic affections and 
malignant disease of the mouth and tongue many cases that belong to 
the long list of affections now classified under the head of surgical 
tuberculosis. The cavity of the mouth is often the seat of slight abra- 
sions and pathological conditions, which may become an infection-atrium 
for the entrance of microorganisms that might be contained in the air 
we breathe, the food we eat, and the water we drink. Remembering the 
frequency with which superficial abrasions and ulcerations occur in this 
localit} r , it is not strange that primary tuberculosis should occasionally 
develop here. The tubercle bacillus produces the same tissue changes 
here as on the surface of the skin, the primary pathological product con- 
sisting of granulation tissue undergoing molecular retrograde tissue 
metamorphosis, followed by ulceration. Ulceration is an earlier occur- 
rence and a more conspicuous clinical feature in tuberculosis of the 
mouth than in some other localities, as the new tissue is constantly 
macerated by the fluids with which it is moistened at all times. The 
tubercular ulcer is generally covered by the products of interstitial 
necrobiosis and superficial coagulation necrosis, which result in the 
formation of what appears as a false membrane. If this membrane, 
when present, is removed, the characteristic granulation surface is 
exposed. The ulcer is surrounded by a zone of inflammatory infiltra- 
tion, which, however, does not present the same feeling of hardness as 
carcinoma. The most characteristic feature of a tubercular ulcer of the 
mouth or tongue consists in the presence of minute tubercle-nodules in 
the margins and underneath the layer of granulations, and, if the infec- 
tion has extended to some distance, in the surrounding mucous mem- 
brane. Schliferowitsch has published an exhaustive resume of the 



574 PRINCIPLES OF SURGERY. 

literature on this subject to date, and has collected all the recorded cases 
in which the diagnosis of tubercular disease of the cavity of the mouth 
could be made with some degree of certainty. The cases number 88, 
and include those of primary and secondary tuberculosis. From a care- 
ful study of this affection he has come to the conclusion that it occurs 
seldom in the very young, and that it attacks most frequently persons 
between 40 and 50 years of age. 

Symptoms and Diagnosis. — Tuberculosis of the mucous membrane 
of the cavity of the mouth appears as a flattened, submucous infiltration 
composed of granulation tissue, which, at an early date, becomes the seat 
of a superficial ulceration in the centre that rapidly extends toward the 
margins of the swelling. Caseation is seldom observed. The cells are 
destroyed by coagulation necrosis, and as they become detached the 
defect increases in size. The appearance of the ulcer in this locality is 
characteristic. If on the tongue, it is found on the borders near the tip 
of the organ. It appears as an oblong ulcer, with raised, ragged borders 
of firmer consistence, showing the color of fresh granulations. The 
ulcer often appears as if covered by a pseudomembrane ; if this cover- 
ing is removed the surface left easily bleeds. The surface of the ulcer 
is uneven, as if covered with hypertrophic papillae. The discharge of 
pus is slight, and, in many cases, miliary nodules may be found around 
the ulcer. Pain is not as severe as in carcinoma. Lymphatic glands 
may become secondarily infected, but this is not often the case. In the 
primary form of the disease, when a positive diagnosis is most difficult, 
the presence of tubercle bacilli will demonstrate the nature of the ulcer. 
A gumma of the tongue, as a rule, develops into a larger swelling than 
a tubercular affection before ulceration takes place, and the resulting 
ulcer is more deeply excavated ; at the same time, other evidences of 
syphilis can usually be detected. Miliary nodules in the immediate 
vicinity of the ulcer are absent in a syphilitic ulcer, and frequently 
present in tuberculosis. If any doubt remain as to the differential diag- 
nosis between these two affections, this should be set aside b} T a course 
of anti syphilitic treatment before resorting to any serious operation. If 
the ulcer is syphilitic it will heal kindly under such treatment, while no 
improvement will be noticeable if it is tubercular. Epithelioma com- 
mences as a superficial infiltration and penetrates the tissues from with- 
out inward. Induration around and underneath the ulcer is more 
marked in an ulcerating epithelioma than in a tubercular ulcer. Glandu- 
lar infection takes place early, and is almost a constant occurrence in 
epithelioma, but is seldom observed in the course of a tubercular ulcer. 
In a case of primary tuberculosis of the tonsils that recently came under 
the observation of the writer the deep glands of the neck were exten- 



TUBERCULOSIS OF MUCOUS MEMBRANE OF INTESTINES. 575 

eively involved, and an examination of the tonsils after their removal 
showed that they were the seat of early and extensive caseation. A 
simple ulcer of the tongue caused by the mechanical irritation from a 
sharp projection of a carious or displaced tooth can be readily recognized 
by the location and character of the ulcer. Such an ulcer may become 
the seat of a tubercular ulcer or the starting-point of an epithelioma. 

Treatment. — The local treatment of a tubercular ulcer of the mouth 
or tongue is the same as when a similar ulcer is located upon the surface 
of the body. If the lesion is circumscribed sufficiently that the wound, 
after complete excision, can be closed by suturing, this method of treat- 
ment should be adopted, as it is certainly the most radical, and results 
most speedily in complete recovery. If the extent of the disease render 
this treatment inapplicable, the diseased tissues should be removed as 
thoroughly as possible by a vigorous use of the sharp spoon, or by 
destroying it with the actual cautery, or both of these measures may be 
combined. The use of superficial caustics has a tendency rather to 
aggravate the disease than to cure it. With a sharp spoon all of the soft 
tissues are scraped awa} r , the healthy tissue being recognized by its 
greater firmness and resistance to the spoon. After bleeding has ceased 
the surface is cauterized with the flat point of a Paquelin cauterjr, and, 
if the disease has dipped in farther at certain points, these are attacked 
by making ignipuncture with the needle-point. The cavity of the mouth, 
during the after-treatment, must be kept as nearly as possible in an 
aseptic condition by dusting the surface daily with iodoform, and by the 
frequent use of a mild, antiseptic mouth-wash, such as a saturated solu- 
tion of acetate of aluminum or boric acid. If all the infected tissues have 
been destroyed healing takes place rapidly b}^ granulation, cicatrization, 
and epidermization after separation of the eschar. If any of the infected 
tissues have remained, the process of healing is retarded or completely 
arrested ; in the latter event a repetition of the same local treatment 
will become necessary. 

TUBERCULOSIS OF THE MUCOUS MEMBRANE OF THE INTESTINES. 

Primary tuberculosis of the intestinal mucous membrane is a com- 
paratively frequent affection, but becomes a surgical lesion only in case 
it leads to intestinal obstruction or perforation. If, as is sometimes the 
case, the infection is limited to a single focus, a timely operation not 
only relieves the symptoms which made surgical treatment a necessity, 
but it may result in a permanent cure. The tubercular lesions of the 
intestinal mucous membrane that occasionally indicate treatment by 
laparotomy are usually found in the lower portion of the ileum, the 
ileo-caecal region, caecum, or ascending colon. Tubercular inflammation 



576 PRINCIPLES OF SURGERY. 

of the large intestine may cause so much swelling as to give rise to 
intestinal obstruction. When the inflammatory process is limited to a 
small portion of the bowel, operative removal of the affected segment is 
justifiable and holds out a fair prospect of permanent relief. Schier 
reports a successful case of this kind. At the close of October, 188T, 
he was consulted b}^ a man who had a painful swelling in the right 
hypochondrium ; the swelling was as large as a man's fist, with a nodular 
surface. Considerable pain, tenderness, emaciation, and evidences of 
intestinal obstruction, which were gradually increasing in intensit}^ A 
tumor of the caecum was diagnosticated, and laparotomy was performed 
November 1st of the same 3^ear. The abdomen was opened by a lateral 
incision. The omentum near the swelling was much inflamed and 
covered with whitish-yellow nodules, from the size of a pin to that of a 
pea. Twelve to sixteen enlarged glands, some as large as a walnut, 
situated along the vertebral column, were enucleated or removed with a 
sharp soon. The csecum was so fragile that it ruptured during the 
manipulations and some faeces escaped. The bowel above and below the 
swelling, which involved the caecum, was emptied by expression, tied 
with rubber bands, and the affected portion excised. The part of the 
csecum containing the valve and the vermiform appendix was left. 
Circular suturing by a double row of sutures. The subsequent history 
of the case was favorable in every respect. Pain was severe for two 
days, and }<ielded to large doses of opium. Eighteen months after the 
operation the patient remained in good health. Examination of the part 
removed showed that the swelling was of a tubercular nature, the sub- 
mucosa and external layers of the bowel being mainly involved. 

Durante reported a somewhat similar case. The patient was a 
woman aged 56, who, for four or five } T ears, had suffered from obscure 
pain in the right iliac fossa when at stool. The pain increased in 
intensity and became paroxysmal, and the patient almost starved her- 
self, with the object of avoiding the torture of defecation. On examina- 
tion a tumor was found in the right iliac fossa, extending downward 
toward the upper outlet of the pelvis. Carcinoma of the caecum or 
neighboring parts was suspected. The abdomen was opened. The 
swelling, as large as a lemon, was found adherent to the iliac fossa, the 
parietal peritoneum and coils of the small intestine being matted to it 
so firmly that the lower end of the latter, measuring 25 centimetres in 
length, together with the caecum and a portion of the ascending colon, 
were removed with it. The two ends of the divided intestine were 
brought together by three rows of sutures. The abdominal wound was 
closed, and the patient made a rapid and permanent recovery. The 
swelling, which had almost completely blocked up the lumen of the 



TUBERCULOSIS OF THE MAMMARY GLAND. 577 

intestine, was found to be of a tubercular nature. Since these cases were 
reported a number of successful operations have been performed for 
tuberculosis of the caecum. If, in cases of intestinal tuberculosis indi- 
cating laparotomy, it should be found, after opening the abdomen, that 
the foci in the ileo-csecal region are too numerous to warrant a radical 
operation by enterectomy, the s} T mptoms can be relieved and the inflamed 
parts excluded from the faecal circulation by establishing an anastomosis 
between the intestine above and below the affected segment by means 
of decalcified, perforated bone-plates. 

TUBERCULOSIS OF THE MAMMARY GLAND. 

A number of well-authenticated cases of primary tuberculosis of the 
mammary gland have recentl}* been reported. So far as the infection is 
concerned, the breast must be considered as an appendage of the skin. 
The bacillus from without may effect entrance into the gland through 
the milk-ducts, in which case the inflammatory process commences in the 
parenchyma of the gland ; or it ma} T enter through a fissure of the nipple, 
in which case the process is primarily interstitial. When direct infection 
from without can be excluded, the disease is the result of auto-infection, 
and on this account the prognosis is alwaj T s more unfavorable. In ref- 
erence to the manner of local infection Mandry distinguishes two forms 
of primary tuberculosis of this gland. The first is very chronic, in 
which the tubercular product is circumscribed, appearing as a firm 
nodular mass, which later undergoes caseation. Abscesses, fistula?, re- 
traction of the nipple, and secondary infection of the axillary glands 
appear in the course of } T ears. The second form is, from the beginning, 
more diffuse and resembles clinically a cold intra-mammary abscess. The 
disease is met with most frequently in women who are nursing, but I have 
repeatedly observed it in young unmarried women. Mandry has observed 
T cases and describes 21 others recorded. One of the 28 was in a male 
patient. Regional dissemination takes place along the chain of axillaiy 
lymphatic glands. Orthmann examined the enlarged lymphatic glands 
in a case of primary tuberculosis of the mamma, and found numerous 
tubercle bacilli. The disease is differentiated from carcinoma 03' the 
absence of pain and hardness in the swelling and from an ordinaiy sup- 
purative mastitis b}' the absence of the prominent S3 7 mptoms of acute 
inflammation. It might be mistaken for a lacteal c} r st or an echinococcous 
cyst, but all doubt as to the nature of the swelling can be set aside by 
an exploratoiy puncture. 

Treatment. — The more expectant plans of treatment recommended 

in the management of tubercular abscesses communicating with the 

primary foci in tissues and organs deeph' situated should not be fol- 

37 



578 PRINCIPLES OF SURGERY. 

lowed in the treatment of tubercular affections of the breast, as in these 
cases a radical operation is not attended 03^ any danger to life, and usually 
results in a permanent cure. The plan to be pursued depends on the 
extent and location of the disease. A superficial limited tubercular 
focus of the mamma can be successfully treated by excising the infected 
tissues. If the process is more deeply located, it may become necessary 
to remove a portion of the mammary gland with it. Partial excision of 
the gland should be done in such a manner as to include the tubercular 
focus in a wedge-shaped section of the gland, the base of the wedge 
being directed toward the periphery of the gland. After excision the 
cut surfaces of the gland are united with buried catgut sutures. If the 
disease has infiltrated the gland extensively, or if a number of sinuses 
have formed, it becomes necessary to extirpate the entire gland. En- 
larged glands are removed in the same thorough manner as in operating 
for carcinoma of the breast. 

TUBERCULOSIS OF THE GENITO-URINARY ORGANS. 

It is only within the last few years that a number of chronic inflam- 
matory processes of the geni to-urinary organs in both sexes have been 
shown to be tubercular in their origin, clinical tendencies, and final ter- 
mination. The susceptibility of the mucous membrane of the genito- 
urinary tract to tubercular infection has been demonstrated experiment- 
ally by Cornet. In rubbing a pure culture of tubercle bacilli in super- 
ficial abrasions of the penis in dogs he produced a tubercular lesion of 
that organ. In bitches, tuberculosis of the vagina and uterus could be 
produced by injections of a pure culture into the vagina. The local 
lesions were followed by general tuberculosis. 

(a) Tuberculosis of Vulva, Vagina, and Uterus. — Direct tubercular 
infection of the genital tract in women has been observed, but the cases 
so far reported are few. Barbier believes that a woman can be infected 
by a tubercular husband during coitus, as bacilli have been demonstrated 
in the semen of tubercular patients, as well as in the discharge attending 
tubercular epididymitis. The uterus may be infected by extension from 
a tubercular lesion of the vulva without any intermediate trace of 
infection in the vagina. The author even admits the possibility that 
tubercular infection may be transmitted by the finger of the attendant, 
by infected instruments, or even through the medium of the air. Zweig- 
baum reports a case of primary tuberculosis of the portio vaginalis uteri 
which, at the time of examination, appeared in the shape of an ulcer 
the size of a walnut, with thick, indurated margins and cheesy floor. 
Numerous tubercle bacilli were found in the secretion taken from the 
surface of the ulcer. Evidences of tuberculosis were apparent at this 



TUBERCULOSIS OF THE GENITO-URINARY ORGANS. 579 

time. After a few weeks the ulcer extended toward the left vaginal wall 
and left labia inajora. A section of a fragment of tissue removed from 
these parts, on staining, showed numerous bacilli. This form of tuber- 
culosis is not frequent, as the author could find onty 2 cases of vulvo- 
tuberculosis in literature, although genital tuberculosis is quite a frequent 
affection. Jonin believes that tubercular endometritis from tocal infec- 
tion is quite a common affection. Of 9 cases which were observed by 
him it was due to sexual contact with men suffering from genital tuber- 
culosis. In 2 others the husbands were tuberculous, but had no genital 
tuberculosis. He calls attention to the fact that Cornil and Chantemesse 
have produced this disease artificially in rabbits by injecting bacilli into 
the vagina. Treub reports the case of a girl who had undergone all 
kinds of treatment, and finally had the uterus scraped out. The append- 
ages then appeared to be perfectly normal. On microscopical exam- 
ination the portions of endometrium removed by the curette were found 
to be tubercular. Two weeks later the patient came under Treub's care. 
It was then uncertain whether the tubes were affected. For six weeks 
she was treated by diet alone, and at the end of that time the tubes 
could be felt, forming sausage-shaped swellings adherent to neighboring 
parts. The uterus and tubes were removed through the vagina, and at 
the operation the peritoneum in Douglas's pouch and the serous coat of 
the uterus were found covered with tubercles. A year and a half after 
the operation the patient was in perfect health. The cases of primary 
tuberculosis of the vulva, vagina, and uterus will undoubtedly become 
more numerous in the literature of the near future, when improved 
methods of examination will enable the surgeon to make a positive diag- 
nosis between these affections and carcinoma and syphilitic lesions. 
The same points in differential diagnosis are to be remembered in this 
connection as have been enumerated in the consideration of tubercular 
affections of the mouth. 

Treatment. — Primary tuberculosis of the utero-vaginal canal and 
vulva should be treated by curetting, and, if the extent of the lesions 
make it necessaiy, by cauterization with the actual cauteiy. Before 
either of these procedures is put into practice the parts must be ren- 
dered aseptic by antiseptic irrigation. Subsequent infection can be 
guarded against by the free use of iodoform, and tamponade of the 
vagina with iodoform gauze. Under ordinary circumstances it is not 
necessary to remove the tampon oftener than once a week, when the 
surface is again freely dusted with iodoform before a new tampon is 
inserted. 

(b) Tuberculosis of Fallopian Tubes. — In the absence of tubercular 
lesions of the vagina and uterus, it is doubtful if infection of the Fallopian 



580 PRINCIPLES OF SURGERY. 

tubes can take place by the entrance of the bacillus through the genital 
tract, and the relatively frequent occurrence of the disease in that part 
of the genital tract is only explainable by attributing it to auto-infection, 
in the same way as we have explained the occurrence, for instance, of 
primary tuberculosis of joints, bone, and peritoneum. We can safely 
assert that tubercular infection of the Fallopian tubes often, if not 
always, takes place upon the basis of pre-existing pathological conditions, 
taking it for granted that the healthy tubes do not present favorable 
conditions for the localization of the tubercle bacilli. A catarrhal con- 
dition of the mucous membrane lining the tubes, as in other organs, 
undoubtedly furnishes, in many instances, the locus minoris resistentise 
for the localization of bacilli brought to the part through the circulating 
blood or by infection from without. 

An interesting case of primary tuberculosis of the Fallopian tubes 
has been recorded by Kotschau. The patient was 45 years old, having 
a good family history; has suffered for a year with pains in the abdomen, 
profuse metrorrhagia, and various nervous disturbances. She was 
treated for retroflexion, and subsequently had an attack of pelveo- 
peritonitis. Vaginal examination disclosed a firm, smooth, movable 
swelling, as large as an apple, to the right of the uterus ; this was taken 
for a malignant ovarian growth, and laparotomy was done for its removal. 
On opening the abdominal cavity a quantity of turbid, purulent fluid 
escaped. The swelling, of oblong shape, was found tying apparently in 
a bed of pus; on account of its intimate adhesions it could not be 
removed. The patient died from shock. The autopsjr showed the 
uterus enlarged and retroverted. The right tube was tortuous and gen- 
erally thickened. Near its distal end it was dilated into a swelling the 
size of a hen's egg, in the centre of which was a cavity containing cheesjr 
material. Other small caseous foci were found in the tubal wall in 
close proximit}' to the large swelling. The ovary on the same side was 
enlarged and transformed into a caseous mass. The left tube and ovaiy 
showed similar changes, though less extensive. The microscopical exam- 
ination of the pathological product confirmed the diagnosis of tubercu- 
losis. Although the disease appears to have been primary in the tubes, 
the affection occurs more frequently from the direct extension of a tuber- 
cular endometritis to the tubes. Lebedeff gives a full description of a 
case that came under his observation. The patient was the widow of a 
man who had died of pulmonary tuberculosis. An examination before 
the operation revealed a firm, nodulated, intra-abdominal tumor in the 
space of Douglas. An attempt was made to remove the tumor by 
laparotomy, but had to be abandoned, as the disease had become too 
widely disseminated. Six weeks la<te*' the patient died with symptoms 



TUBERCULOSIS OF THE GENITO-URINARY ORGANS. 581 

of general tuberculosis. At the post-mortem miliary tuberculosis was 
found in the peritoneum, lungs, colon, uterus, and Fallopian tubes. The 
most advanced stages of the disease were found in the uterus and Fallo- 
pian tubes, showing that the disease had commenced in these organs. 
Both of the Fallopian tubes were dilated and filled with pus, the epithe- 
lium in parts being absent. Stained sections from the uterus and tubes 
showed the presence of numerous bacilli. 

Symptoms and Diagnosis. — Tubercular salpingitis, occurring as a 
secondary lesion to a primary tuberculosis in the lower portion of the 
genital tract, can be suspected if, in connection with a cervical or 
endometritic tuberculosis, examination reveal a swelling in the region of 
one or both Fallopian tubes. Primary tubercular disease of the Fallo- 
pian tubes gives rise to local conditions and symptoms that it would be 
impossible to differentiate from an ordinary p t yosalpinx. The existence 
of a dilated, inflamed Fallopian tube can generally be made out with 
some degree of certainty by making the examination while the patient 
is under the influence of an anaesthetic. Werth has described an acute 
and chronic form of tubercular salpingitis. In the acute variety both 
the muscular and serous coats undergo caseous degeneration, numerous 
bacilli being found in the interior of the tube ; while in the chronic form 
the wall of the tube undergoes thickening and infiltration with new cells, 
and its contents contain only a few bacilli. The increase in size of the 
tube is due to the collection of pus in its interior as well as to the thick- 
ening of the wall. When suppuration takes place in the interior of the 
tube the tubercular product has become the seat of a secondary infection 
with pus-microbes ; hence indications for operative treatment have become 
more urgent. If the tubercular inflammation extend from the abdominal 
extremity of the Fallopian tube to the peritoneum, sj'mptoms of tubercular 
salpingitis are obscured later on by those of tubercular peritonitis. 

Treatment. — As a tubercular salpingitis calls for the same treatment 
as a pyosalpinx, it is, for all practical purposes, only necessary to narrow 
the diagnosis down to either one of these two affections before resorting 
to treatment by laparotomy. A median incision is preferable to a lateral, 
as frequently both tubes are affected simultaneous^. Salpingectom}^ 
should be combined with oophorectomy, as the ovaries are frequently 
implicated in the tubercular process, and these organs -would be of no 
further use after extirpation of the tubes. As tubercular tubes are usual!}' 
found firmly adherent to the surrounding tissues, their removal is often 
attended with the greatest difficulties, and may become an impossible 
task. If the disease is limited to the tube-structures, and has not in- 
volved surrounding important organs, it would appear rational, under 
such circumstances, to lay the tube open, remove its contents, scrape out 



582 PRINCIPLES OF SURGERY. 

the infected tissues as far as possible, arrest bleeding by applying the 
actual cautery, and, after thorough iodoformization, pack with iodo- 
form gauze. This treatment would certainly appear more rational than 
to be content with an exploratory incision and allow the patient to re- 
main a sufferer until relieved by death from tuberculosis. In one case 
that came under my treatment, where both tubes were imbedded in a 
mass of granulation tissue, I was unable to remove the entire mass, 
was compelled to pursue this course, and the patient recovered quickly 
and permanently, in spite of a faecal fistula that formed a few days after 
the operation. 

TUBERCULOSIS OF GLANS PENIS AND URETHRA. 

Kraske has observed a case of tubercular ulceration of the urethra, 
extending from the membranous portion of the neck of the bladder, in 
a patient, 33 years of age, who was treated for chancre. The autopsy 
revealed advanced tuberculosis of the genito-urinaiy tract and pulmonary 
tuberculosis. In another case, a man 49 years old, a tubercular ulcera- 
tion existed on the dorsum of the glans the size of a cent piece. This 
sore was also mistaken for a primary lesion of syphilis. There were no 
signs of pulmonary tuberculosis. The glans was amputated, when it 
was observed that the tubercular infiltration extended deeply into the 
cavernous structure. The lesion could not be traced to genital contact, 
and under the microscope showed the typical structure of tubercular 
tissue. In the examination of doubtful lesions of the glans penis it is 
well to remember the possibility of tubercular infection in this locality, 
and;, in case the tubercular nature of a lesion can be established on suffi- 
cient grounds, to resort to cauterization with the actual cautery, excision, 
or amputation, according to the location and extent of the disease. 

TUBERCULOSIS OF EPIDIDYMIS AND TESTICLE. 

In the male genital apparatus tuberculosis attacks most frequently 
the epididymis, for the reason that the vessels in this structure are more 
tortuous and smaller than in the remaining portion of the testicle or the 
vas deferens, both of which are important elements in determining locali- 
zation in that part from floating bacilli that reach it through the circu- 
lating blood. Salzmann states that these anatomical conditions are im- 
portant factors in the arrest and localization of floating bacilli. That in 
cases of tuberculosis of the testicle we are only dealing with an external 
manifestation of an antecedent infection becomes apparent by the clinical 
observation that not infrequently both testicles are infected, either simul- 
taneously or some time apart, showing that the infection came from the 
same source. Guyon (" La Castration pour le Sarcocele tuberculeux," 



TUBERCULOSIS OF EPIDIDYMIS AND TESTICLE. 583 

Ann.des Mal.des Org. Genito-urin., 1891, vol. ix.No. ^believes that tuber- 
culosis of the geni to-urinary organs occurs quite frequently as a primary 
affection. He is of the opinion that tuberculosis of the epididymis is 
almost always complicated by a similar affection of the prostate and 
vesiculse seminales, and is therefore, on the whole, opposed to castration 
as a curative operation. He maintains that this operation is only justi- 
fiable after the disease of the epididymis has resulted in the formation of 
abscesses and fistulous openings. Tuberculosis of the genital organs in 
the male furnishes one of the best examples of the typical clinical course 
of local tuberculosis. The disease extends, by continuity of structure, 
often to a great distance from its starting-point. Nothing is more 
familiar than the clinical course of a case of tuberculosis of the testicle. 
A small, hard nodule is first detected in the epididymis, and from this 
point the whole structure of the epididymis is infected, when the infection 
slowly, but surely, extends to the testicle ; then along the vas deferens 
to the vesiculae seminales, the prostate gland, and bladder, and from this 
viscus along the ureters to the pelvis of the kidney. As a rule, the 
disease remains limited to the genito-urinary organs, but in some in- 
stances metastatic infection takes place, either from the genito-urinary 
organs or from the primary source of the infection. A gentleman was 
under my care whose case illustrates a number of interesting points 
descriptive of the clinical behavior of genital tuberculosis. He was 35 
years of age ; married for ten years ; the marriage had been childless. 
He claimed that he never had syphilis or gonorrhoea. Tuberculosis is 
hereditary in the family. Nine years before he noticed a small, hard swell- 
ing in the epididymis of both testicles. Two years before symptoms 
of cystitis appeared, which were not much improved by internal medi- 
cation and antiseptic irrigation of the bladder. Six months before his 
left knee became swollen and painful. Four months later he commenced 
to suffer severe pain in the region of the left kidney. Temperature varied 
from 100° to 103° F. A swelling soon formed in the left lumbar region, 
and four weeks later I evacuated a large quantity of pus through a lumbar 
incision. Through the incision the kidney could be seen and felt, and, 
by passing the index finger around it, it appeared to be extensively sep- 
arated from the contiguous structures. The left knee presented all the 
appearances of advanced S3 7 novial tuberculosis. No evidences of pul- 
monary tuberculosis. The disease in both testicles had made no progress 
for years, and the infiltration appears to be limited to the epididymis. 
The epididymis on both sides is moderate^' swollen and indurated. The 
vas deferens on each side is somewhat larger and firmer than normal. 
The disease had extended from the epididymis to the pelvis of the kidney 
on both sides, all of the intervening organs being involved in the tuber^ 



584 PRINCIPLES OF SURGERY. 

cular process. The only apparent manifestation of general tuberculosis 
was presented by the left knee. An interesting feature in this case was 
the formation of a paranephritic abscess around a p3 T elonephritic kidney, 
which must be regarded as the result of a secondary infection with pus- 
microbes. 

Symptoms and Diagnosis. — Tubercular epididymitis always appears 
as a chronic affection, in this respect differing from gonorrhoeal epididj 7 - 
mitis and the ordinary form of acute parenchymatous and suppurative 
orchitis. Pain and tenderness are either entirely absent or, at least, 
slight when present. Circumscribed hydrocele may develop as soon as 
the disease extends to the tunica vaginalis. The tubercular inflamma- 
tion is characterized by the same pathological conditions as in other 
organs, new nodules appearing in the neighborhood of the first one, 
which, by confluence, form masses of considerable size. Caseation is an 
early and almost constant condition. In many cases the process extends 
in the direction of the skin ; a tubercular abscess forms in the tunics of 
the scrotum ; the skin presents a bluish-red color, and spontaneous per- 
foration gives rise to evacuation of the abscess. Frequently multiple 
abscesses form in this manner, and the fistulous openings lead down to 
caseous masses. In some cases, as the one reported, the disease in the 
epididymis becomes latent, but the infection extends at an early date 
along the vas deferens, which becomes swollen, hard, and nodular, and 
from which, if a cross-section is made, the characteristic cheesy material 
can be squeezed. From the vas deferens the disease extends to the 
vesiculse seminales, prostate gland, bladder, and finallv creeps along the 
ureters to the pelvis of the kidney, usually simultaneously on both sides. 
The only disease with which tubercular epididymit is might be confounded 
is tertiary syphilis affecting the same part of the testicle. In cases of 
doubt the patient should be placed on antisy r philitic treatment for a few 
weeks, which, if the affection is tubercular, will produce no impression 
on the swelling; on the other hand, if it is sy T philitic, it will rapidly 
diminish in size. 

Treatment. — The only radical treatment in tuberculosis of the epi- 
didymis and testicle is castration. This operation is indicated if the 
disease is limited to one testicle, and no evidences of tuberculosis can 
be found in any other organ be}^ond the reach of surgical treatment. I 
have removed both testicles in two cases, but in both patients tubercular 
cystitis developed one and two years, respectively, after the operation, 
and in one of them the immediate cause of death was pulmonaiy tuber- 
culosis. My own cases and the experience of other surgeons would tend 
to dictate a conservative course of treatment if both testicles are 
affected. In performing castration for malignant or tubercular affections 



TUBERCULOSIS OF THE VESICUL^ SEMINALES. 585 

of the testicle the surgeon should aim to remove as much of the sper- 
matic cord as possible. The inguinal canal should be laid open freely 
and, by patient traction on the cord, as much as possible of this structure 
beyond the internal inguinal ring should be secured and removed. After 
the disease has extended to the organs at the base of the bladder or 
the bladder itself, castration is, of course, positively contra-indicated. 
Reboul, of Marseilles, treated three cases of this disease by injections 
of naphthol-camphor. He injected 4 to 5 drops every eight to ten days 
into the thickened tissues of testicle and epididymis. Marked improve- 
ment was effected, the diseased parts becoming more indurated and con- 
tracted ; and these results are the more noteworthy since in two of the 
cases other measures continued for a long time had been unsuccessful. 
The co-existence of pulmonary tuberculosis, or tuberculosis of any of 
the larger joints, would furnish a sufficient ground against the pro- 
priety of castration. Castration is a legitimate operation, and yields 
fair results if the patient is otherwise in good health and the disease is 
limited to one side, and has not extended along the cord beyond a point 
where all of the infected tissues can be removed. The tunica vaginalis 
should always be removed with the testicle, and, if the scrotum is 
adherent at any point, the adherent portions of the skin must be excised 
at the same time. The vessels of the cord should be tied separately, as 
tying the cord en masse gives rise to unnecessary pain, and the ligature 
is liable to slip, — an occurrence that might be followed b} T troublesome 
haemorrhage. 

TUBERCULOSIS OF THE VESICUL^ SEMINALES. 

In 1829 Dahmar described a chronic inflammation of the seminal 
vesicles, the description of which corresponds closely to that of tubercu- 
losis. Since then this affection has been described b} r Albers, Jaye, 
Naumann, Humphrey, and Kocher, and lately it has been studied by 
Ra} r er, Cruveilhier, and Reclus as secondary to pulmonarj- tuberculosis. 
As a secondary affection this ailment is not only seen in connection with 
tuberculosis of the lungs, but is more common after primary tubercu- 
losis of the epididymis, either as a continuation of the cheesy degenera- 
tion in the vas deferens or spreading b} T contiguity of tissue from the 
sides of the prostate. Primary tuberculosis of these organs is ex- 
tremely rare, and still less often diagnosed, and up to quite recently no 
surgical interference has been attempted. Ullmann now reports a case 
of primary tuberculosis of the right testicle, with secondary affection 
of the seminal vesicles on both sides, in a lad 17 years of age, where, 
after removal of the right testicle, he extirpated these organs through a 
semilunar incision in the perineum. The general health of the patient 



586 PRINCIPLES OF SURGERY. 

improved after the operation, but a small urinary fistula remained, which 
formed in consequence of injury to the base of the bladder during the 
operation. He is of the opinion that the seminal vesicles should be re- 
moved in primary tuberculosis of the testicle or epididymis, when no 
suspicious symptoms have appeared on the sound side, and when on the 
affected side the vesiculse seminales are already attacked ; also in cases of 
primary tuberculosis of the seminal vesicles. More recently Roux, of 
Paris, has advanced the idea that in tuberculosis of the genital organs it 
is a mistake to remove only the testicles, since he has often observed 
fistulse and abscesses extending along the cord after castration. He 
advises, in addition, extirpation of the vas deferens and seminal vesicles. 
He reports two cases in which, after removal of the testicle, the vas 
deferens was carefully separated from the vessels of the spermatic cord, 
which were then tied and divided. An incision was then made in the 
perineum, the vesiculse seminales pushed into the wound by the finger 
introduced into the rectum and excised, and the vas deferens entirely 
removed. The results were excellent. The impotence following the 
operation should be no contra-indication, for in all reported cases of 
tuberculosis of the seminal vesicles impotence always occurs in a short 
time ; in fact, it is regarded as a cardinal symptom of the disease. 

TUBERCULOSIS OF THE BLADDER. 

Tuberculosis occurs either as a primary or secondary affection. 
Several cases of well-marked primary tuberculosis of the bladder in 
the female have come under my observation, where the disease evidently 
commenced at the neck of the bladder, and, after spreading over the 
whole internal surface of the viscus, extended along the ureters to the 
pelves of the kidneys, and finally, in the course of a few } r ears, proved 
fatal from tubercular p}^elonephritis. Primary tubercular cystitis appears 
to be more frequent in females than in males, undoubtedly because, on ac- 
count of shortness of the urethra, direct infection is more liable to occur. 

Striimpell, after a careful study of 4 cases of primary tuberculosis 
of the bladder in men, came to the conclusion that infection takes place 
through the urethra. The tubercle bacilli, finding no favorable place for 
localization and growth in the urethra and bladder, finally reach the 
prostate gland or the epididymis, the whole process resembling what 
occurs in inhalation tuberculosis, in which the disease manifests itself 
not in the mucous membrane of the bronchial tubes, but in the paren- 
clryma of the apices of the lungs. 

Symptoms and Diagnosis. — Tuberculosis of the bladder is clinically 
characterized by S}^mptoms of cystitis, the intensity of the symptoms 
varying according to the part of the bladder affected, the extent of the 



TUBERCULOSIS OF THE BLADDER. 587 

disease, and the presence or absence of complications. If the disease 
primarily involve the neck of the bladder, tenesmus and frequent desire 
to urinate are the most distressing symptoms. As long as no ulceration 
of the vesical mucous membrane has taken place, the urine may present 
a perfectly normal appearance, and, on examination, is found normal 
in other respects. Very frequently the symptoms become very much 
aggravated shortly after an examination of the bladder, made upon the 
supposition that the patient is suffering from stone in the bladder, as the 
introduction of a sound without the necessary antiseptic precautions is 
often followed by a secondary infection with pus-microbes, which gives 
rise to an acute suppurative cystitis. The general health of the patient 
now becomes rapidly undermined, and the extension of the local disease 
in the direction of the kidneys is hastened. The urine contains large 
quantities of pus and mucus, and becomes ammoniacal from the presence 
and action of putrefactive bacteria. The walls of the bladder become 
greatly thickened from inflammatory exudation and tubercular infiltra- 




Fig. 166.— Tubercle Bacilli in Urine. (Cornil and Babes.) 

tion ; the organ is unable to empty itself completely, and the decomposed 
residual urine becomes an additional source of irritation and progressive 
infection. Incontinence of urine is a frequent symptom in advanced 
vesical tuberculosis, and is usually an indication that the organ is ex- 
tensively diseased. In secondary tuberculosis of the bladder it is usually 
not difficult to locate the primary disease, and thus establish a positive 
diagnosis. The presence of tubercle bacilli in the urine in cases of 
primary tuberculosis of the organ furnishes a positive diagnostic crite- 
rion between ordinary cystitis and vesical tuberculosis. In the absence 
of ordinary causes of cystitis, such as gonorrhoea, stricture of the ure- 
thra, enlarged prostate, calculus, and tumors of the bladder, sj'mptoms 
of C}'stitis point strongly toward a tubercular origin of the inflammation, 
and should induce the surgeon to make a most careful examination in 
reference to the etiology and nature of the cystitis. It is only by ex- 
cluding the presence of the different lesions of the bladder by a careful 
and thorough examination of that viscus and its neighboring organs, as 
well as a chemical, microscopical, and bacteriological examination of the 



588 PRINCIPLES OF SURGERY. 

urine, that a positive diagnosis of vesical tuberculosis can be made during 
the early stages of the disease. In tuberculosis of the pelvis of the 
kidney or bladder free bacilli can often be found, and sometimes their 
presence can be detected in the cells. Tuberculous urine injected into 
the peritoneal cavity of a guinea-pig will produce tuberculosis in this 
animal, and in doubtful cases this diagnostic measure may prove of 
great value. 

Prognosis and Treatment. — In secondary tuberculosis of the bladder 
the regional infection has extended so far that even the most heroic 
surgical measures will necessarily fail in eliminating the disease, and 
death from extension of the disease to the kidneys, or from secondary 
pulmonary or general tuberculosis, will follow as an inevitable result. In 
primary vesical tuberculosis the disease, at the time a positive diagnosis 
can be made, has usually invaded so much of the walls of the bladder 
that a radical operation would necessitate an extensive resection of its 
walls, after which it would be found impossible to utilize the remaining 
portion of the organ as a reservoir for the urine. Resection of the wall 
of the bladder has been done in several instances in the treatment of 
malignant tumors at its base, but has usually terminated in the formation 
of a permanent urinary fistula. 

Dr. R. Harvey Reed, of Mansfield, Ohio, has recently made an in- 
teresting series of experiments on dogs, with a view to dispense with 
the bladder altogether in cases of extensive disease of this organ, neces- 
sitating partial or complete excision. He has shown that the ureters can 
be successfully implanted into the rectum, thus excluding permanently 
the urinary tract below this point from the urinary passages, and utiliz- 
ing the rectum as a reservoir for the urine. If the operation of im- 
plantation of the ureters into the rectum can be perfected to such an 
extent as to become a feasible and practical procedure in surgery, it may 
be possible, in the future, that vesical tuberculosis can be successfully 
dealt with by complete excision of the affected organ. 

The conservative treatment of vesical tuberculosis by injection of 
solutions of boric acid, benzoate of soda, the ordinary antiseptic solu- 
tions, and iodoform has little or no effect, either in affording palliation 
or in retarding the regional extension of the disease. Guyon recom- 
mends corrosive sublimate as an excellent remedy in cystitis, but espe- 
cially in vesical tuberculosis. The remedy is employed either in the form 
of irrigation or instillation, the latter being preferred by the author. 
The strength of the sublimate solutions varied from 1 to 5000 to 1 to 1000. 
At the beginning of treatment 20 to 30 drops are injected into the 
posterior urethra, and this quantity is gradually increased to 60 drops. 
The more severe the pain, the less should be the quantity injected. 



TUBERCULOSIS OF THE BLADDER. 589 

Before the instillations the bladder must be emptied. The remedy that 
has yielded better results in my hands than any other in the local treat- 
ment of vesical tuberculosis is trichloride of iodine. The treatment 
must be commenced with a very weak solution, — J per cent., the 
strength gradually increased to 1 per cent, as the bladder becomes more 
tolerant to the action of this drug. The bladder should first be washed 
out with sterilized water and not more than an ounce of the solution 
injected at a time. Internal medicines, such as boric acid, benzoate 
of soda, uva ursi, buchu, and triticum repens, are of utility in relieving 
vesical tenesmus, before secondary infection with pus-microbes and 
putrefactive bacteria has occurred, by rendering the urine alkaline and 
more copious; but during the later stages of the disease they are 
useless even as palliatives. If the tubercular process is limited to 
the urinary passages below the ureters, incision and drainage of the 
bladder secure rest to this organ and open up a direct route for the 
more effectual treatment of the tubercular lesions, and thus not only 
constitute the most efficient palliative measure, but also the most 
effective procedure in retarding the local extension of the disease by 
direct, vigorous, antitubercular treatment. I had an opportunity to 
observe the palliative effect of an opening in the bladder, in a case of 
primary vesical tuberculosis in a female aged 35 years, where the tuber- 
cular ulceration resulted in the formation of a vesico-vaginal fistula. 
The tenesmus was promptly relieved, as soon as the bladder was placed in 
a condition of rest, by the escape of urine through the fistulous opening. 
In the female the most direct route into the bladder, and affording 
the most efficient drainage and furnishing the most advantageous con- 
ditions for the local treatment of the tubercular lesions, is a vaginal 
cystotomy made near the neck of the bladder The opening should be 
at least 1^- inches in length, extending from near the neck of the bladder 
in an upward direction. Tubular drainage should be dispensed with, as 
all foreign substances in the bladder not onty act as irritants, but interfere 
with complete drainage. As the opening is made in the most dependent 
portion of the bladder, free drainage can be secured most efficientl}- b} r 
means which prevent contraction or closure of the vesico-vaginal open- 
ing. This can be done by suturing the mucous membrane of the bladder 
to the vaginal mucous membrane, thus establishing a permanent bimu- 
cous fistula between the bladder and the vagina. Through this opening 
accessible tubercular lesions can be treated by the use of the sharp spoon 
and the direct application of iodoform. The parts below this opening 
should be protected against the irritating effect of urine b}' applications 
of vaselin or lanolin containing one of the milder antiseptic remedies. 
After the fistulous opening has been established the bladder can be 



590 PRINCIPLES OF SURGERY. 

irrigated with antiseptic solutions, or a mixture containing iodoform, 
through the urethra. 

In the male the same objects are attained most efficiently by making 
a suprapubic cystotomy, as through a perineal incision the direct treat- 
ment of tubercular lesions is impossible. The fistulous communication 
should be made complete by suturing the margins of the visceral wound 
to skin flaps taken from each side of the external incision, — a method first 
suggested by Morris, of New York. By lining the margins of the 
incision with mucous membrane and skin, the loose connective tissue in 
the prevesical space is protected against infection, and the fistulous 
opening is rendered permanently patent. At the time of operation 
visible tubercular ulcers are curetted and iodoformized. The bladder 
can be irrigated subsequently through the urethra or through the 
fistulous opening. 

In a case of advanced primary tuberculosis of the bladder where I 
pursued this method of treatment the operation afforded marked relief, 
but appeared to have no influence in retarding a fatal termination, as the 
disease had already extended to the kidneys. The patient lived for 
nearly two months in comparative comfort, the principal complaint made 
being the moisture caused by the constant escape of urine through the 
artificial urethra. 

A case is described by Battle in which recovery followed curetting 
through a suprapubic incision, after the failure of less formidable means. 
The patient was a girl aged 20 years. The operation was performed 
July 29, 1889. The patient was discharged September 20th, and April 
8, 1890, was in good health and working at her trade. 

In cases where the disease in the bladder is circumscribed, and the 
organ is opened early, the treatment might, occasionally at least, result 
in a permanent cure, if the infected tissues can be completely removed 
by curetting or destroyed by the actual cautery through the incision 
at the time of operation. In such favorable cases the opening should 
not be allowed to close until the surgeon can satisfy himself that the 
ulcers have completely healed, and that no new centres of infection are 
present. 



CHAPTER XXIII. 

Actinomycosis Hominis. 

Actinomycosis is a form of chronic inflammation caused by the 
presence of actinomyces or ray-fungus. Until quite recently this disease 
was included among the malignant tumors, and we have reason to 
believe that, in many of the reported cases after operations for sarcoma, the 
disease for which the operations were done was not sarcoma, but actino- 
mycosis. Before degeneration of the inflammatory product has taken 
place actinomycosis resembles a tumor more closely than any other 
inflammatory swelling. The swelling is composed largely of granulation 
tissue, which, on examination under the microscope, presents a histo- 
logical structure that, in the absence of other evidences, it would be 
difficult or impossible to differentiate from a round-celled sarcoma. The 
presence of the specific fungus in the granulation tissue settles the 
diagnosis. 

HISTORY OF THE DISEASE. 

The disease, as occurring in cattle, was first described by Bollinger, 
in 187 7, as a condition in which sarcoma-like tumors were met with, 
associated with a peculiar growth which, from its structure, was named 
" Strahlenpilz " (ray-fungus), or actinou^ces. James Israel was the 
first to recognize the disease in man, but it was not generally understood 
until the appearance of the classical work of Ponfick (" Die Aktino- 
mykose des Menschen," Berlin) in 1882. Numerous articles on this 
subject have since appeared in the current medical literature, so that 
Partsch, in 1888, mentioned in his monograph seventy-five references, 
with a supplemental list of thirty-three names furnished by Schuchardt. 
Since the publication of Israel's case numerous cases have been reported 
by different observers, representing German}', England, Belgium, Switzer- 
land, Russia, Austria, France, and America ; so that Partsch in his paper 
estimates the whole number up to that time at not less than one hundred. 
While most of the articles in medical journals contain onty a descrip- 
tion of isolated cases, it appears to have been the good fortune of some 
of the writers on this subject to meet with a number of cases in a com- 
paratively short time. Thus, Hochenegg reports 7 cases that came 
under his observation, and Moosbrugger has increased the list of 
published cases by 10 well-authenticated and carefully recorded cases. 

(591) 



592 



PRINCIPLES OF SURGERY. 



Rotter observed 13 cases in two years. Albert has seen not less than 
38 cases of actinomycosis in man within the past few years ; of these 
8 have come under his observation during the two years. These cases 
have come mostly from Vienna and its vicinity. 

DESCRIPTION OF FUNGUS. 

The ray-fungus, or actinomyces, is not, strictly speaking, a microbe, 
as it is large enough to be seen with the naked eye ; but its identity can 
only be ascertained from its characteristic structure, which requires the 
use of the microscope. Bollinger described as peculiar to this disease 




Fig. 167.— Ray-Fungus, with One of the Rays More Projecting and 

Branching. (Ponfick.) 



certain yellow bodies, visible to the naked eye, alwaj^s found in the pus 
of actinomycotic abscesses and in the granulation tissue before suppu- 
ration had occurred. Microscopically, thejr were found to consist of 
threads similar to the ordinary mycelium, which terminated in bulbous 
ends. 

The threads radiate from the centre, and their clubbed extremities 
impart to the fungus the characteristic ray-like appearance. Sometimes 
but one of these bulbs is connected with a thread ; at other times there 
may be several. In some specimens one of the rays projects far beyond 



PLATE IV. 




Actinomyces from a Section of a Maxillary Tumor of a Cow. Weigert's 
Method. Orseille and Gentian-Violet. Zeiss ^ o.i., Oc. 4. (After 
Crookshank.) 



DESCRIPTION OF FUNGUS. 593 

the others and terminates by several bulbous ends, as is shown in Fig. 167. 
In man the actinomyces occurs as a small, globular mass, commonly 
about the size of a millet-seed, usualty of a pale-yellow color, but at times 
white, brown, green, or speckled, the color being influenced by age and 
the consecutive pathological conditions by which it may be surrounded. 
In man the clubbed bodies are often absent, and the growth then consists 
of the radiating filaments alone. The rays, when immersed in water or 
in a weak solution of chloride of sodium, become enormously swollen and 
lose their shape ; while they effectually resist the action of acids, ether, 
and chloroform. 

Clinical experience and bacteriological research appear to prove that 
infection in animals and man can take place with fragments of actino- 
mycoses, and that the resulting pathological conditions are the same as 
when the whole fungus is inserted into the tissues. Gross observed the 
polymorphous character of the actinomyces which could present them- 
selves in the form of single bacilli or rods, while the well-known club 
shapes were absent. Ponfick has regarded the fungus as a polymorphous 
bacteria since 1851. He is agreed as to the influence of particles of the 
fungus in the production of the disease, and in support of this view re- 
lates the case of a boy who had swallowed a bristle. Some months later 
an actinomycotic abscess formed upon the back, in which, on opening, 
the bristle was found. 

Staining. — For staining the actinomyces, Weigert uses Wedl's 
orseille ; Marchand, eosin ; Dunker and Magnussen, cochineal-red ; Moos- 
brugger, hsematoxylin-alum ; and Partsch, in section-staining, has had the 
best results with Gram's method. Recently, Babes has made beautiful 
dry preparations b} r using a 2-percent, solution of safranin in aniline-oil, 
followed by treatment with iodide of potassium. 

0. Israel has found that a solution of orcein in acetic acid stains the 
rays a Bordeaux red, while the filaments, if decolorization is not carried 
too far, present a blue tinge. Baranski uses picrocarmine for staining 
fresh preparations of actinomyces bovis. A small amount of the contents 
of a yellow nodule, or pus from the part, is spread in a thin layer on a 
cover-glass and dried in the air. The cover is then passed three times 
through the flame of an alcohol-lamp, care being taken not to overheat 
the preparation. It is then floated in the picrocarmine solution, or a 
few drops of the staining fluid are placed on the cover. The whole 
process of staining is completed in two or three minutes. The cover is 
then carefully washed by agitating it in distilled water and alcohol, and 
examined in water and glycerin. The fungus takes a }^ellow color, while 
the remaining structure appears red. 

Cultivation Experiments. — It has been found extremely difficult to 

38 



594 PRINCIPLES OF SURGERY. 

cultivate the actinomyces outside of the body, probably on account of 
the usual culture media not being well adapted for its growth. The first 
successful experiments were made in 1886 by Bostrom, of Giessen, upon 
plates of coagulated blood-serum and agar-agar, the fungus attaining its 
maturity in five or six days, when it presented the typical structure of 
actinomycosis as found in man. O. Israel cultivated the fungus success- 
fully upon coagulated blood-serum. Upon this medium the culture 
grows very slowly and the fungus often undergoes calcification. Israel 
made the observation that water, glycerin, blood-serum, and weak saline 
solutions seriously impair the vitality of the fungus, and he maintained 
that the effect of these agents on the actinomyces explains the failure 
of previous culture and inoculation experiments. If evaporation is pre- 
vented, a thin, velvety layer forms on the surface of the blood-serum in 
about eight weeks, in the vicinity of which, not before the expiration of 
fourteen days, cell-nodules appear more in a downward direction than on 
the sides of the inoculation streak. From the tenth to the fourteenth 
day numerous spores are produced and a thick wall of club-shaped 
mycelia in typical centrifugal arrangement. 

At a meeting of the medical society of Berlin, March 5, 1890, M. 
Wolff made a communication in which he described culture experiments 
witli actinomj'ces which he made jointly with James Israel. He an- 
nounced that they had succeeded in cultivating the fungus in and upon 
coagulated albumen of egg and agar-agar. The material used was taken 
from a case of retromaxillary actinomycosis immediately after the 
abscess was incised. With the yellow granules stab and streak inocu- 
lations were made, using agar-agar as a soil. It was found that the 
actinom} T ces is not a purely anaerobic fungus, as it grew upon the surface 
as well as in the depth of the culture soil. The agar culture appeared 
first as transparent little drops, which, by confluence, made an opaque, 
white mass. Under the microscope the culture was seen to be composed 
of short, thick rods, with an admixture of other elements. The egg 
cultures, on the other hand, were made up of short, thick rods besides a 
mass of threads, some of them twisted in the shape of a cork-screw, pre- 
senting an intricate net-work of threads. With these cultures successful 
inoculation experiments were made. 

Inoculation Experiments. — In 1883 James Israel succeeded in pro- 
ducing the disease artificially in a rabbit by introducing a fragment of 
actinonrycotic tissue into the peritoneal cavitj^. Somewhat later Pon- 
fick made successful inoculation experiments in calves by implantation 
of infected granulation tissue under the skin into the abdominal cavity 
or directly into veins. Rotter experimented on calves, pigs, dogs, 
guinea-pigs, and rabbits, and in only one instance, a rabbit, did he 



SOURCES OF INFECTION. 595 

succeed in reproducing the disease. In this case a piece of granulation 
tissue the size of a bean was inserted into the peritoneal cavity, and 
the animal having manifested no symptoms of disease, was killed six 
months after the inoculation. On opening the abdominal cavity, about 
twenty nodules, varying in size from the head of a pin to a hazel-nut, 
were found distributed over a considerable surface around the graft, each 
of them showing the typical histological structure of actinomycosis. 
The transplanted piece of tissue was found perfectly encapsulated in 
one of the nodules the size of a bean. As the fungus was found in 
all the nodules, it is 011I3* reasonable to conclude that the disease spread 
from the original focus by migration of some of the new fungi, which, 
at their respective points of localization, established independent centres 
of infection and tissue proliferation. While the actinomyces in the new 
nodules presented a perfect structure, and could be readily stained, the 
transplanted fungus in the graft had lost its structure, and could no 
longer be stained. The first successful inoculation experiments with 
pure cultures were made by Wolff and James Israel. Three rabbits 
were inoculated by injecting a pure culture into the peritoneal cavity. 
The post-mortem showed numerous nodules upon the parietal perito- 
neum, the omentum, and between the intestinal coils. The nodules varied 
in size from the head of a pin to that of a hazel-nut, and each of 
them was surrounded by a fibrous capsule. The interior of each nodule 
was composed of a yellow mass the consistence of tallow. Typical 
actinomjrces were found imbedded in masses of round cells in a state of 
fatty degeneration. 

In a later series of experiments the same author inoculated 23 
animals with a pure culture grown upon sterilized agar-agar. Of the in- 
oculated animals 18 were rabbits, 3 guinea-pigs, and 1 sheep. In most 
of them it was done in the peritoneal cavity. In every instance the 
result was positive except in the sheep. Pure cultures were made from 
the inoculation product. At the Tenth International Medical Congress 
Gross, of Krakau, reported a case of actinomycosis of the sternum, with 
the pus of which he had made an inoculation into the anterior chamber 
of the eye, with positive results. At the same meeting Hanau stated 
that he had inoculated the anterior chamber of the eye with actinom}'- 
cotic material, with the same positive results. 

SOURCES OF INFECTION. 

As regards the histoiy of the parasite outside the body, as }-et only 
a few facts are known. It is found in pig-meat, and is peculiarly sus- 
ceptible to outside influences. Virchow found the fungus as a small, 
calcareous concretion in the muscle-fibres of the pig, and considered 



596 PRINCIPLES OF SURGERY. 

its flesh highly dangerous as food unless well cooked. As the actino- 
m3 T ces found in man and beast resemble each other morphologically and 
in their effect on the tissues, as well as in their reaction to chemical sub- 
stances, it is evident that the etiology of the disease is similar in both. 
The fungus has never been found outside of the hody. Israel is of the 
opinion that both man and animals are infected from the same source, 
such as vegetables or water. Jensen traced an epidemic in Seeland to 
the eating of rye grown on land recently reclaimed from the sea ; and 
Johne discovered a fungus closely resembling actinomyces in grains 
of rye stuck in the tonsils of pigs. That the ears of barlej^ or rye are 
sometimes the carriers of the fungus is well illustrated by the case 
reported by Soltmann. The patient was a boy who had swallowed an 
awn of barle}'. The foreign body lodged in the pharynx, where it gave 
rise to difficulty in deglutition ; afterward it perforated the pharyngeal 
wall, — an accident attended by haemorrhage, — and later an actinomycotic 
phlegmon developed; it spread rapidly, and finally opened below -the 
scapula. Through this opening the foreign body was extracted. Piana 
examined the tongue of a cow suffering from a circumscribed actinomy- 
cosis of this organ, in which the disease could be traced to a similar 
origin, — perforation of the tissues and infection by a sharp beard of an 
ear of barley. That actinomycosis prevails in an endemic form is well 
shown by the investigations of Preusse. He examined 244 cattle and 
found 23 affected by some form of the disease. He attributes the disease 
to feeding the cattle with straw and hay that had been spoiled by sub- 
mersion. He was, however, not able to find the fungus in the fodder. 
Actinomycosis has as yet only been found amongst herbivorous and 
omnivorous animals, including man, and the frequent location of the 
primary swelling in the mouth seems to indicate that the fungus gains 
entrance with food. 

PATHOLOGY AND MORBID ANATOMY. 

As to the manner in which the fungus exerts its pathogenic action 
much yet remains to be ascertained. The most striking effect is the 
transformation of mature connective tissue into embryonal or granula- 
tion tissue. The fungus possesses no pyogenic properties. It gives rise 
in the tissues to a low grade of chronic inflammation, and becomes 
imbedded in the specific product of tissue proliferation, — granulation 
tissue. 

The product of inflammation around each fungus consists of granu- 
lation tissue, which, under the microscope, might be easily mistaken for 
tubercle or sarcoma tissue. At first the cells are round ; at a later stage 
of the inflammation epithelioid and giant cells are formed immediately 



PATHOLOGY AND MORBID ANATOMY. 



597 



around the fungus. As the disease is almost always attended by sup- 
puration at some time during its course, it has been customary to ascribe 
to the actinomyces pyogenic properties. Israel has always held that the 
actinomj'ces is a pus-producing fungus, in opposition to Ponfick and 
other pathologists, who claim that when suppuration takes place it is the 
result of a secondary infection with pus-microbes. As cases of actino- 
mycosis have been recorded in which the disease remained stationary in 
the granulation stage, for an indefinite period of time, without suppura- 
tion taking place, and pus-microbes have been cultivated from the pus 
of actinomycotic abscesses, it appears more than probable that suppura- 
tion occurred independently of the presence of the fungus, and was pro- 
duced by the specific action of pus-microbes on the granulation tissue. 
Firket asserts that the actinomyces does not appear to produce coagula- 
tion necrosis, but, from a study of 
the earliest-formed colonies, he 
finds that the first effect of the 
fungus is to induce cellular lryper- 
plasia. It is as if the tissue ele- 
ments resented the intrusion of 
the parasite,which, however, mostly 
gains the upper hand ; so that the 
result is the formation of granula- 
tion tissue and, later, abscesses that 
characterize the disease. Suppura- 
tion takes place earliest when the 
disease occupies a location where 
secondary infection with pus-mi- 
crobes is most liable to occur. As 
a rule, it may be stated that, the 
earlier suppuration takes place, 
the more rapid is the spread of the 
disease and the graver the prognosis ; while the absence of suppuration 
indicates comparative benignity, and points in the direction of a more 
chronic form of the affection. 

The localized chronic form of actinomycosis resembles, in its clini- 
cal features and its anatomical locations, more closely sarcoma than 
any other affection, and is most frequently mistaken for this form 
of malignant growth. In such cases it would be difficult, if not im- 
possible, in the absence of the specific fungus, to make a differential 
diagnosis between it and round-celled sarcoma, even b}^ a most careful 
microscopical examination, as the histological structure of both is almost 
identical. 




Fig. 168.— Actinomyces. Section from Ac- 
tinomycotic Swelling. X 300. (ffluegge.) 



598 PRINCIPLES OF SURGERY. 

CLINICAL VARIETIES. 

If infection take place by fully-developed actinomyces, it can only 
do so by the fungus gaining entrance into the tissues through some loss 
of continuity in the cutaneous or mucous surface ; any other method of 
ingress is impossible on account of the large size of the fungus. In the 
cases in which no such primary infection-atrium could be found, it must 
be taken for granted that the local lesion had healed between the time 
infection took place and the first manifestations of the disease, or that 
infection was caused by the entrance of spores, which, from their 
smaller size, could possibly find their way into the tissues through 
intact mucous surfaces. In reference to the primary localization of the 
disease, Moosbrugger gives the following statistics : In 29 cases the 
lower jaw, mouth, and throat were affected ; in 9, the upper jaw and 
cheek; in 1, the tongue; in 2, the region of the oesophagus; in 11, the 
intestines ; in 14, the bronchial tract and the lungs ; in 7 the point of 
entrance could not be ascertained. Infection may take place through 
any abraded surface brought in contact with the specific cause, and for 
clinical purposes the cases may be divided into the following three 
groups: 1. Cutaneous surface. 2. Alimentary canal. 3. Respiratory 
tract. 

I. Cutaneous Surface. — A number of well-authenticated cases of 
primary actinomycosis of the skin have been placed on record. Partsch 
describes a case of actinomycosis developing in the scar left after extir- 
pation of the breast. The patient was a man aged 60 years. In June, 
1884, his left breast was removed for an ulcerating carcinoma. As the 
wound did not heal by primary union, and the process of cicatrization was 
very slow, a number of small skin-grafts from a perfectly healthy j^oung 
man were transplanted. The wound was practically healed in September. 
Two months later the cicatrix ulcerated and an abscess discharged itself. 
Actinomyces were found in the pus. The parts were excised, and the 
progress of the disease was apparently arrested. No explanation could 
be made as to how the infection occurred. Hochenegg reported a case of 
primary actinomycosis of the skin in the left submaxillary region. He 
attributed the disease to an invasion of the fungus through a small 
atheroma. 

In Kaposi's case, when the disease was first noticed, it appeared as 
a red spot, the size of a florin, on the left pectoral muscle, which gradu- 
ally increased to the size of a walnut and then gradually flattened down 
and disappeared. Meanwhile, fresh spots and lumps appeared, some as 
large as a pigeon's egg. Eleven years after the beginning of the disease, 
a swelling as large as an apple appeared over the spine of the sixth ver- 
tebra, which gradually extended forward and, a year later, formed a large 



CLINICAL VARIETIES. 599 

tumor behind the right axilla. A }^ear later this swelling had diminished 
in size to that of a pigeon's egg, and then again increased in size. Ulcera- 
tion set in, exposing a fungous, bleeding surface. At this time the entire 
trunk, but not the limbs, was covered with nodules, spots, and stripes. 
The infiltration was located in the corium. This case is remarkable for 
the chronicity of the disease, the multiple points of regional infection, 
and the limitation of secondary infection with pus-microbes to a few 
isolated nodules. 

At the meeting of the German Society of Surgeons, in 1889, Leser 
reported 3 cases of primary actinomycosis of the skin that had come 
under his own observation in the course of a single year. In his remarks 
on this subject he placed special stress on the manner in which the 
disease extends. In the periphery of the primary lesion he found 
numerous minute nodules, later becoming the seat of destructive 
changes, resembling in this respect the clinical features of tuberculosis 
of the skin. The extension of the disease in the direction of the deep 
tissues takes place by the formation of passages corresponding to the 
size of a lead-pencil ; these are filled with yellowish-gray or reddish-gray 
granulations, which attack and destroy tissues, irrespective of their 
anatomical structure. The lymphatic glands were always found intact. 

2. Alimentary Canal. — The frequency with which the disease affects 
the mouth and jaws of cattle is explained by the occurrence of numer- 
ous points of injury caused by masticating rough food, that furnishes 
the necessary infection-atrium through which the fungus invades the 
tissues. 

Teeth. — In man infection takes place frequently through carious 
teeth, and through abrasions in the gums and mucous membrane of the 
mouth. Israel found the fungus in the cavities of carious teeth, and 
Partsch detected in the same locality almost pure cultures without any 
manifestation of disease except chronic peri-odontitis. The fungus 
occurs here often side by side with leptothrix. 

Tongue. — Hochenegg saw a case of actinomycosis of the tongue 
caused by an infected carious tooth. The swelling was the size of a 
cherry, located near the apex of the organ. The affection had existed 
for two months. The growth was excised, and on examination was 
found to consist of granulation tissue, with a central yellow mass the size 
of a millet-seed. Besides this case only 3 cases of actinomycosis of the 
tongue are on record, — 1 primaiy, 1 secondary to disease of the jaw, 
and 1 metastatic. 

Jaws. — That carious teeth furnish a frequent infection-atrium in 
maxillary actinon^cosis is well known, and in many instances the 
disease in its early stages has been mistaken for an ordinary dental 



600 PRINCIPLES OF SURGERY. 

affection, and patients have often sought relief at the hands of a dentist. 
The lower jaw is most frequently affected, the growth being connected 
with the bone or situated close to it, or it has already extended to the 
submental or submaxillary region. The disease often pursues a chronic 
course, closely simulating periosteal sarcoma, until it reaches the loose 
tissues of the neck, when rapid extension takes place, in a downward 
direction, along the subcutaneous connective tissue and the inter- 
muscular septa. Israel refers to a case in which the actinomycotic 
swelling in the submaxillary region extended, in five months (August 
to December), to the level of the thyroid cartilage. When the disease is 
primarily located in the upper jaw, which, however, occurs only in excep- 
tional cases, it tends to invade rapidly the adjacent soft parts, and even 
to implicate the base of the skull and the brain. The prognosis is 
abvnys more serious when the disease affects the upper than the lower 
jaw, as the tendency here to invade the deep structure is much 
greater. Two cases of actinomycosis in man have come under my 
observation, and as both of them originated in the mouth, and repre- 
sent, from a prognostic point of view, two distinct classes, I will describe 
them briefly. 

The first patient was a man 30 years of age, German by birth, and 
a soda-water manufacturer by occupation. His business required him to 
make frequent trips into the country by team. He had no recollection 
of having come in contact with cattle suffering from " swelled head" or 
"lumpy jaw." During the winter of 1886 he suffered from what he 
supposed was an ordinary cold ; the right side of the lower jaw was 
swollen and painful. As one of the molar teeth showed evidences of 
decay and had become loose, it was extracted. The pain and swelling, 
however, did not improve, and the attending physician extracted all of 
the molar teeth of the lower jaw on that side. At this time a fungous 
mass commenced to appear over the surface of the edentulous bone. 
The cheek on the affected side was also greatly swollen. The patient 
was admitted into the Milwaukee Hospital about six months after the 
first symptoms had appeared. At this time the lower jaw, in the mouth, 
presented a fungous mass extending from the angle of the bone to the 
first bicuspid ; the swelling extended as far as the tonsil. The cheek 
was enormously swollen from the angle of the mouth to the lower 
margin of the parotid gland. The skin over the swollen part presented 
a pale, glossy appearance, and the superficial veins were considerably 
dilated. Around the margin of the swelling- no distinct border-line 
could be felt, the infiltrated parts fading gradually into the healthy sur- 
rounding tissues. Free suppuration from the surface of the fungous 
granulations, and a number of small abscesses had discharged themselves 



CLINICAL VARIETIES. 601 

into the cavity of the mouth. As some doubt existed as to the char- 
acter of the inflammation, careful and repeated examinations were made 
of the pus removed from the small abscess-cavities, and on several occa- 
sions fragments of actinomyces were found. The discovery of the 
specific cause of the inflammation cleared up the diagnosis and furnished 
an urgent indication for operative treatment. An incision was made 
along the lower border of the jaw from just below the articulation to 
near the symphysis, and, after arresting all haemorrhage, it was carried 
into the cavity of the mouth. The alveolar processes of the jaw were 
affected, and were removed with chisel and cutting-forceps. Wherever 
the periosteum showed signs of infiltration it was carefully scraped 
away, and finally the whole bone surface was thoroughly cauterized. The 
infiltrated soft tissues were dissected out with knife and scissors ; the 
disease was found to have extended as far as the tonsil. The bottom of 
the wound was iodoformized and packed with iodoform gauze, while the 
external wound was sutured. The entire external wound healed b}^ 
primary union, and the cavity in the mouth closed slowly by granula- 
tion. The patient's general health continued to improve rapidly, until 
six weeks after the operation, when the neck below the scar became 
swollen, followed in a short time by the formation of abscesses reaching 
from the angle of the jaw to the clavicle, and posteriorly as far as the 
spine of the scapula. Numerous openings were made and efficient 
drainage established, but suppuration continued unabated, and the 
patient became extremely emaciated. The suppurative inflammation 
extended, and four months after the first operation the patient died ; the 
symptoms during the last days of life pointed to a hypostatic pneumo- 
nia. Actinomyces were continuously found in the pus during the entire 
course of the disease. I believe that the recurrence of the disease was 
due to imperfect removal of infected tissues in the posterior and lower 
portion of the pharynx. 

The second case came under my care during the summer of 188T. 
The patient was a young man, employed on a farm. About five months 
before he was admitted into the Milwaukee Hospital he had a number of 
teeth extracted from the right upper jaw, under the belief that the teeth, 
some of which were decayed, were the cause of the pain and swelling in 
that region. The physician in attendance diagnosed sarcoma of the 
upper jaw, and sent the case to me for operation. On my first examina- 
tion, I found a swelling involving the right side of the face, extending 
from the zygomatic arch to near the lower border of the lower jar, in- 
volving the deep tissues, and connected with the alveolar processes of 
the posterior portion of the upper jaw. The swelling was firm and with- 
out well-defined margins. No evidences of suppuration. The history 



602 PRINCIPLES OF SURGERY. 

of the case, and particularly the location, extent, and physical properties 
of the swelling, led me to the opinion that it was the result of actinomy- 
cotic infection. All infected tissue was thoroughly excised through a 
large external incision, the jaw-bone scraped and cauterized. The entire 
thickness of the cheek, with the exception of the skin and superficial 
fascia, appeared to be transformed into granulation tissue. In the granu- 
lations numerous minute yellowish-gray bodies were found, which, under 
the microscope, showed the t}^pical structure of the ray-fungus. The 
mycelia were not so bulbous as we find them pictured in the books, but 
the distal extremity appeared to be surrounded by dust-like bodies, pre- 
senting the appearance of a small brush. These minute granules I re- 
garded as spores. In the first case, in which suppuration had taken 
place, I never succeeded in finding the actinomyces perfect and com- 
plete; in the second case the granulation tissue had not been destro} T ed 
by suppuration, and the fungus was found in a perfect condition and in 
a state of fructification. These cases present a striking contrast, both in 
regard to the local condition and the ultimate termination. In the first 
case secondary infection with pus-microbes had alread}^ taken place, and 
the phlegmonous inflammation that followed this occurrence prepared 
the tissues again for the diffusion of the actinomycotic process ; while 
in the second case the inflammatory process had not passed beyond the 
granulating stage, and the boundary -line between healthy and diseased 
tissue was also more distinctly marked, — a most important factor in the 
operative treatment. The first patient died from recurrence of the disease 
in the vicinity of the operation wound and its extension to the neck and 
chest; while in the second case the wound healed, and the patient has 
remained in perfect health since. 

3. Intestinal Canal. — In primary intestinal actinomycosis the disease 
is caused by ingress of the fungus with food or water, and its implanta- 
tion upon the mucous surface. At the point of implantation the fungus 
multiplies, and by its growth invades the submucous tissue, which 
becomes the seat of active tissue proliferation. Arrest and implantation 
of the actinomyces are determined by antecedent pathological changes. 
Chiari has given an excellent account of the pathological condition found 
in a case of intestinal actinonrycosis that came under his observation. 
The patient was a man 36 years of age, who during life presented, as 
the most prominent clinical feature, progressive marasmus. At the 
necropsy chronic tuberculosis in the apices of the lungs and a few 
tubercular ulcerations in the lower portion of the ileum were found. The 
large intestine presented a very remarkable appearance, the mucous mem- 
brane of which, except the csecum and ascending colon, was covered with 
whitish deposits, forming round and oblong patches, some of them 1 



CLINICAL VARIETIES. 603 

cubic centimetre in diameter and 5 millimetres in thickness. In some of 
these patches could be seen minute yellowish-brown and yellowish-green 
granules. The patches were firmly adherent, and when removed left a 
loss of substance in the mucous membrane. The mucous membrane 
throughout was in a state of catarrhal inflammation. On microscopical 
examination tbe granules proved to be actinomj'ces. The mycelium 
had penetrated into the tubular glands and showed calcified, club-shaped 
conidia. The calcification of the club-shaped extremities had undoubt- 
edly prevented deeper penetration of the fungus. Hochenegg presented 
a case of actinomycosis to the Medical Society in Vienna in a man 43 
years of age, who had sustained an injury of the abdomen nine months 
previously, and had since that time noticed a painful swelling at the seat 
of injury. In the region of the umbilicus a fistulous opening formed, 
which continued to discharge a thin secretion, in which actinomyces were 
constantly found. The patient was very much emaciated and many of 
the teeth carious. There was no swelling about the jaws or neck. Ex- 
amination of the organs of the chest and the sputum revealed no addi- 
tional diagnostic information. The author expressed the opinion that 
the inflammatory swelling caused by the contusion furnished the necessary 
conditions for the localization of actinomyces from the intestinal canal. 

Zemann reports 5 cases of actinonrycosis of the abdomen. In 4 
of them the disease commenced with sharp, lancinating pains in the 
abdomen, and during their course presented the clinical picture of 
chronic peritonitis. Swellings could be found in one or more places in 
the anterior abdominal wall, and the abscesses were either incised or 
opened spontaneously, and in 3 cases they communicated with the in- 
testinal canal. The first case was a woman, 30 years of age, who had a 
fistulous opening in the anterior abdominal wall which communicated 
with a swelling in the left parametrium. The patient stated that this 
swelling appeared soon after her last childbed. A constant discharge of 
yellowish-red pus was maintained, in which, under the microscope, nu- 
merous actinomyces could be seen. The patient died of exhaustion, and 
at the post-mortem chronic para- and peri- metritis were found, with ex- 
tensive pus-cavities that communicated with the rectum and bladder. 
The second case occurred in a person 18 years of age, who, during life, 
had suffered from a large abscess in the abdominal cavit} r , under the 
right lobe of the liver, which communicated with the intestinal canal, 
and had led to numerous fistulous openings in the anterior abdominal 
wall. 

At the necropsy a loop of the ileum was found perforated and in 
communication with the abscess-cavit}^. The pus contained numerous 
actinomyces. In the third case the diagnosis was made post-mortem by 



604 PRINCIPLES OF SURGERY. 

the discover}^ of actinon^ces in the pus. The disease was located in 
the lower portion of the ileum and caecum, where it had caused suppura- 
tion and numerous adhesions. A most remarkable and interesting 
history is connected with the fourth case. A robust, well-nourished 
woman, 40 years of age, was attacked quite suddenly with pain in the 
stomach, high temperature, diarrhoea, and vomiting, followed b} 7 cerebral 
symptoms and death. At the necropsy the right Fallopian tube was 
found transformed into a large abscess, both extremities of the tube 
closed, and walls of sac lined with granulations containing actinomyces. 
The fifth patient was 50 years of age, and had suffered for a long time 
from lancinating pain in the abdomen ; a fistulous opening formed in the 
umbilical region and discharged a thin, yellowish-green pus. The post- 
mortem showed actinomycosis of the peritoneum, small intestine, left 
ovaiy, and liver ; large abscess among the intestinal coils ; perforation of 
small intestine and bladder. In the upper part of the small intestine 
small pigmented cicatrices were found. In all of the above cases the 
microscopical examination revealed the presence of actinom} T ces in the 
granulation tissue as well as in the pus of the abscess-cavities. In a 
case of intestinal actinomycosis reported b} 7 Langhans, the disease 
started evidently from the appendix vermiformis, 4 centimetres in 
length, the end of which appeared as if transversely cut in an abscess- 
cavity the size of a walnut. The abscess was on the right side of the 
bladder, and so deep in the pelvis that during life it could not be located. 
The abscess pursued a chronic course, and the walls were well denned ; 
no signs of chronic or acute peritonitis. Furthermore, the mucous 
membrane of the appendix was studded with cicatrices, and presented a 
slate color. The principal seat of the actinomycotic process was in the 
liver. In a second case reported by the same author the clinical course 
of the disease resembled perityphlitic abscess. The necropsy showed 
perforation of the caecum and ascending colon. No cicatrices in the 
mucous membrane or surrounding tissues. In all probability, the 
perforations occurred from without inward. 

Luening and Hamm have recently reported, with interesting details, 
a case of primary actinomycosis of the colon with metastatic deposits 
in the liver. The patient was a man 28 years of age, who, in 1880, 
suffered from an acute abdominal affection, which at the time was 
diagnosed as typhlitis. Four years later a second attack occurred, 
attended by symptoms of intestinal obstruction. Patient was very ill 
for eight days, when the symptoms of obstruction subsided, and he 
made a slow recovery. During the year 1887 he had a third attack, 
attended by high fever and absolute constipation for eight to ten days. 
During the month of December of the same year he had another but less 



BRONCHIAL TUBES AND LUNGS. 605 

severe attack, and at this time a hard swelling made its appearance in 
the right side of the abdomen. From this time until he was admitted 
into the hospital, April 5, 1888, he was confined to bed. The patient 
was at this time greatly emaciated, with a temperature of from 38.4° C. 
to 39.8° f C. Swelling the size of a fist in the right side of the abdomen, 
half-way between umbilicus and anterior superior spine of the ileum. 
Externally this swelling presented redness and oedema. Fluctuation 
indistinct. Deep palpation showed that the swelling extended to right 
hypochondrium ; abdomen not tympanitic. Swelling painful and tender, 
pain extending to spermatic cord and testicle on same side. A few days 
later abscess was incised, and nearly a quart of brownish pus, having a 
faecal odor, escaped. Digital exploration revealed an irregular cavity, 
whose walls at some points were plainly lined with intestinal coils. 
Disinfection and drainage. As the symptoms did not improve materially, 
the abscess-cavity was again scraped out and disinfected four weeks 
later. After the second operation it was noticed that the pus contained 
yellow granules, which, under the microscope, were shown to be actino- 
myces. The abscess was incised a third time, but the patient kept losing 
ground, and died October 9th. The autopsy revealed primary actino- 
mycosis of the ascending colon, with multiple fistulous perforations. A 
metastatic actinomycotic abscess of the liver had perforated into the 
hepatic vein, resulting in multiple metastases in the lungs. The cases 
of intestinal actinomycosis reported above warrant the opinion that the 
mucous membrane of the intestinal canal is frequently the seat of 
primary localization of the actinomyces, thus corroborating the state- 
ments of Johne in reference to this disease in animals. 

BRONCHIAL TUBES AND LUNGS. 

If an actinomyces should be inhaled with the inspired air, and 
should become implanted upon the bronchial mucous membrane, and 
find favorable conditions for its growth, the granule will become sur' 
rounded by new cells derived from the pre-existing epithelial cells, and 
thus become the centre of a minute granuloma. 

By multiplication of the actinomyces new nodules are produced, 
around each of which the pre-existing tissue is transformed into 
embryonal tissue, which in time is destroyed, resulting in suppuration 
and loss of tissue. Israel reported a case of actinomycotic abscess of 
the lung caused by the entrance of an infected tooth into the air- 
passages. In this instance the fungus was conveyed into the bronchial 
tube with the carious tooth, and the infected foreign body became the 
centre of the specific inflammation. 

Cases of primary actinomycosis of the lungs, however, have been 



606 



PRINCIPLES OF SURGERY. 



observed where no such direct carrier of the contagium could be found, 
and in which infection must have occurred by the direct inhalation of 
the fungus or its spores with the inspired air. Szenasy found, in the 
case of the wife of a butcher, who had suffered for nine years from 
severe pain in the right side of the chest, latterly attended by a severe 
cough, in the right mammary region, a fluctuating swelling, the size of a 
hen's egg, covered with normal skin. On the outer side of this swelling, 
in the intercostal space between the third and fourth ribs, another swell- 
ing existed, double in size and elongated in shape, and with indistinct 
margins. This latter swelling has been noticed for nine years, and was 
tender to the touch. Auscultation over the fourth and fifth intercostal 
spaces on the healthy side revealed bronchial breathing and diffuse 
bronchial rales. Temperature, 38.4° C. (101.1° F.). The urine contained 
a trace of albumen. By aspiration 150 cubic centimetres of thick, yellow 




Fig. 169. 



C~- 



-ACTINOMYCES FROM LUNG OF COW. FUNGUS IN THE CENTRE OF 

Inflammatory Product. X 350. (Marchand.) 



A, normal epithelial cells of bronchus attached to connective tissue ; B, large epithelioid cells ; C, leucocytes. 

pus were removed, and contained colonies of actinomyces. Actinonryces 
were also found in the sputum. The patient had carious teeth, but no 
signs of actinomycosis could be detected in the mouth. 

Canali relates the clinical history of a girl, 15 years of age, who 
had suffered for eight years from a cough, attended by a scanty, fetid 
expectoration. Inspection and percussion yielded only negative results. 
Auscultatory symptoms pointed to a diffuse catarrh. Under the micro- 
scope the sputum was seen to contain pus-corpuscles, epithelial cells, and 
numerous actinomyces. No primary source of infection could be found 
in the mouth, pharynx, or nose. 

Moosbriigger interprets the mechanism of the ingress of actinomyces 
by assuming that the fungus enters the bronchial tubes during inspira- 
tion, and becomes at first deposited upon the mucous membrane, where 
its presence and growth cause a destruction of the epithelial cells, when 
it reaches the submucous and peri-bronchial tissues, in which a nodule 



ACTINOMYCOSIS OF BRAIN. 607 

of granulation tissue is produced that by pressure induces degenerative 
changes and gradual destruction of the bronchial wall for further infec- 
tion. He believes that the peri-bronchial lymphatic vessels and glands 
take an active part in the local diffusion of the process, as the}' furnish 
an avenue for the dissemination of the fungus or its spores. He claims 
the existence of an actinonrycotic lymphangitis, but confesses that he 
has never seen the fungus inside of lymphatic vessels. As soon as the 
fungus reaches the pulmonary tissues, it gives rise to parenchymatous 
inflammation, whose first product is always granulation tissue, which, at 
a later stage, and under the influence of a secondary infection with pus- 
microbes, undergoes transformation into pus-corpuscles and the formation 
of abscesses. 

ACTINOMYCOSIS OF BRAIN. 

Quite recently, Bollinger placed on record the first case of primary 
actinomycosis of the brain. The patient was 26 years of age. The 
intra vitam diagnosis was tumor of the brain ; the most prominent symp- 
toms were severe headache, paralysis of left abducens, congestion of 
optic papilla, and momentary unconsciousness. The swelling in the 
brain, found on autopsy, presented the characteristic features of a cysto- 
myxoma in the third ventricle ; all of the ventricles were found consid- 
erably dilated. The swelling contained numerous colonies of actinomyces 
in all possible stages of development. The tendency to suppuration of 
the tissues, usually found in all cases of actinomycosis in man, was 
entirely absent in this case. This case, if any, appears to be one of 
cryptogenetic infection, as the fungus or spores must have entered 
somewhere through the cutaneous or mucous surface without producing 
the disease at the primary portio invasionis, and, localizing in the brain 
by embolism, resulted in primary actinomycosis in this organ. 

Keller reported a case of metastatic actinomycosis of the brain 
in which a correct diagnosis was made during life. The patient was 
a middle-aged woman, who suffered from pleurisy, and six months 
thereafter an abscess developed over the cartilages of the sixth and 
eleventh ribs, in the pus of which actinomyces were found. Two 
years later increasing paresis of left arm developed, followed by 
convulsions, confined at first to the arm, then becoming general, and 
at times identical with cortical epilepsy. Diagnosis of actinomycosis 
affecting the motor area was made ; operation was suggested and 
declined. The paresis extended to left lower extremity and left side 
of face ; later, convulsions, headache, vomiting, and loss of conscious- 
ness, soon deepening into coma. Burger then obtained consent to 
operate. The patient was moribund, and required no anaesthetic. He 
exposed the right ascending parietal convolution, incised the dura mater 



608 PRINCIPLES OF SURGERY. 

and the discolored brain-surface, and removed 2 ounces of thin, greenish 
pus, in which were found actinomyces in great abundance. When the 
pus was evacuated, she recovered from the deep coma, and, while still on 
the operating-table, called for water. On the following day consciousness 
returned, and on the eighth the facial paralysis disappeared. In two 
months the wound had healed and the paralytic lesions improved, but 
there remained some paresis of left arm, with contraction of the fingers. 
In less than one yea,v there was a recurrence of the symptoms, and Burger 
re-opened the brain-abscess, followed by the escape of a considerable 
quantit} 7 of pus. No material improvement followed, and the patient 
died a few days thereafter. 

At the post-mortem, the middle third of the right frontal and 
parietal convolutions was occupied b}^ a large mass of newly-formed 
tissue, protruding over the surface and reaching into the substance of 
the brain for one inch. Underneath it, deeply buried in the white sub- 
stance, an unopened, encapsulated abscess, the size of a nutmeg, was 
discovered. 

SYMPTOMS AND DIAGNOSIS. 

Actinomycosis is an inflammatory disease that clinically is noted 
for its chronicitjr. The specific product, composed of granulation tissue, 
is abundant, and the swelling, often of considerable size, resembles more 
a tumor than an inflammator}' swelling. The extension of the morbid 
process takes place by diffusion of the actinomyces in loco, in preference 
along the loose connective-tissue spaces, each fungus constituting a 
nucleus for a nodule of granulation tissue. By confluence of many such 
nodules the inflammatory swelling often attains a very large size, and 
when suppuration occurs in the interior the further history is that of 
chronic abscess. Regional dissemination of the infective process never 
takes place through the lymphatic glands. When the Emphatic struc- 
tures become implicated, it is an indication that secondary infection has 
taken place. In exceptional cases the disease pursues quite a rapid 
course, and may then be mistaken for an acute phlegmonous inflamma- 
tion, osteomyelitis, or, when diffused over a large surface of the body, for 
syphilis. A good illustration of the former class is furnished by the 
case reported by Kapper. A soldier, 22 years of age, became suddenly 
ill with febrile symptoms and a rapidly-increasing swelling of the lower 
jaw. An early incision was made and liberated a large quantity of pus, 
which, on microscopical examination, was found to contain actinomyces. 
It is interesting to note that in this case the various teeth from where 
the infection had evidently taken place contained threads of leptothrix 
and actinomyces. 

At a meeting of the Berlin Medical Society, about six years ago, 



SYMPTOMS AND DIAGNOSIS. 609 

0. Israel gave an accurate description of the post-mortem appearances 
of a case of diffuse actinomycosis. The patient, a woman 44 years of 
age, had been treated for syphilis in one of the surgical clinics. The 
heart contained a number of minute abscesses containing the fungus in 
large numbers. A large abscess between the diaphragm, stomach, and 
spleen contained thick pus of a greenish color, — an unusual occurrence in 
cases of actinomycosis, — but no actinomyces. The spleen was the seat of 
large and numerous minute abscesses, and the liver and kidneys also 
contained small abscesses, and in all of them actinon^ces were found. 
Israel claims that this case affords a good illustration of his view that 
the actinom} r ces, as regards its effect on the tissues, occupies a position 
half-way between the bacillus of tuberculosis, which produces only granu- 
lation tissue, and the pus-microbes, which produce pus. It was im- 
possible in this case, as in so many others in which multiple deposits 
have been found, to locate with accuracy the primary seat of infection. 
The teeth were perfect and the whole digestive tract showed no evidence 
of disease. Metastasis in actinomj'cosis takes place in the same manner 
as in pyaemia and malignant tumors. At the primary seat of infection 
the fungus or its spores gain entrance through a defective vein-wall into 
the general circulation, and, at the point of arrest in a distant capillary 
vessel, establish an independent centre of infection, with all the attri- 
butes of the primary infection. General infection is of rare occurrence 
in actinomycosis, as this disease is noted for its tendency to extend 
locally, where it often results in extensive regional dissemination and 
destruction of tissue. Actinomycosis resembles, in its clinical behavior, 
very closely the malignant tumors, in that it will invade every tissue 
with which it comes in contact, irrespective of its anatomical structure. 
Primary localization is very apt to occur in the connective tissue, and in 
preference it extends along this structure; but periosteum, bone, muscles, 
tendons, cartilage, — in fact, all of the tissues of the body, — succumb to 
the fungus as quickly as they become infected. 

In actinonrycosis of the jaws and the vertebrae we often find exten- 
sive destruction of bone, with large abscesses communicating with the 
primary lesion. Before suppuration takes place the actinon^cotic swell- 
ing is quite firm on pressure, and, if the disease extend rapidly, it is 
surrounded by a diffuse oedema. Pain and tenderness are usually never 
severe, and often almost wanting. Redness appears as soon as the in- 
fection has extended to the skin. Suppuration usually develops in con- 
sequence of direct infection with pus-microbes through some minute 
surface defect in the swelling. As soon as suppuration sets in, the swell- 
ing not only increases rapidly in size, but regional diffusion is hastened 
by the breaking down of the granulation tissue that before held the 



39 



610 PRINCIPLES OF SURGERY. 

fungi fixed in their respective localities. The same tendency to migra- 
tion of an actinomycotic abscess is observed as in tubercular abscess. 
The characteristic feature of actinonrycotic pus is the presence of minute, 
macroscopical, yellowish granules ; the actinomyces, on careful inspection, 
can almost always be discovered. If these granules are placed under the 
microscope their characteristic structure will at once become apparent. 

In cases of actinon^cosis of any of the internal organs, attended by 
suppuration and discharge of pus through some one of the outlets 
of the body, the diagnosis will usually depend almost exclusively upon 
the detection of the fungus in the discharges. Microscopical examina- 
tion of the sputum and faecal discharges, in cases of suspected actinomy- 
cosis of the lungs or the intestines, is the only positive means of making 
a differential diagnosis between these affections and pulmonary and in- 
testinal tuberculosis. Actinomycosis of the skin, mouth, tongue, and 
jaws might be mistaken for sarcoma, carcinoma, tuberculosis, and syph- 
ilis. As, with the exception of carcinoma, all of these affections present 
under the microscope a histological structure that it would be often dif- 
ficult to identify microscopically, the differential diagnosis by means of 
the microscope must rest on the detection of the ray-fungus imbedded in 
the granulation tissue. Sarcoma does not suppurate or break down as 
early as the actinon^cotic or tubercular swelling. Carcinoma primarily 
starts in the epiblast or hypoblast, and, even during the earliest period 
of the growth, there is no difficult}^ in demonstrating an intimate relation- 
ship between the skin or mucous membrane and the tumor encroaching 
upon the mesoblast. In actinomycosis, tissue proliferation takes place 
around each fungus in the mesoblast, and the skin or mucous membrane 
is infected and destroyed from within outward. In tuberculosis, regional 
infection almost always occurs through the medium of the lymphatic 
vessels and glands, while these structures are seldom or never invaded 
in actinomycosis. In the absence of microscopical proof of the nature 
of the lesion, it may become necessary to resort to a therapeutic test in 
differentiating between syphilis and actinomycosis. Large doses of po- 
tassic iodide, administered four times a da}^, will have a decided effect in 
reducing the size of a gumma in the course of two or three weeks, while 
no such prompt result will be obtained if the lesion is of an actino- 
mycotic nature. 

PROGNOSIS. 

Actinomycosis is a more dangerous affection than tuberculosis. 
While a spontaneous cure not infrequently takes place in the latter, we 
have no proof that actinomycosis ever terminates in such a satisfactory 
manner without the surgeon's aid. Actinon^cosis of the internal organs 
proves fatal almost without exception on account of the inaccessibility 



TREATMENT. 611 

of the disease to radical surgical treatment. In such cases numerous 
fistulous openings form, discharging profuse quantities of pus, and the 
patient dies in from one to two or three years from exhaustion or amy- 
loid degeneration of the internal organs. If the disease is located in 
external parts, local extension often takes place very slowly until sup- 
puration sets in, when the actinomycotic abscess migrates from place to 
place, attacking all the tissues that come in its way, and life is finally 
destroyed by pyaemia, sepsis, or exhaustion. The prognosis is alwaj^s 
favorable when the disease is recognized early, and when it is located in 
parts accessible to a radical operation. As metastasis is of rare occur- 
rence in actinomycosis, complete removal of the primary focus is followed 
by a permanent cure. 

TREATMENT. 

Thomassen and Nocard first called attention to the value of the 
internal administration of potassic iodide in the treatment of actino- 
mycosis in animals. Soon after the publication of their results of this 
method of treatment, Van Iterson resorted to the use of the same remedy 
in the treatment of the same disease in man with an equally satisfactory 
result. Buzzi and Galli-Valerio have also reported a successful case. In 
this case the disease affected the whole right side of the face, from the 
temple to the clavicle. Large doses of the drug were administered, with 
the effect of promptly diminishing the profuse suppuration, followed 
ultimately by a complete cure without further surgical intervention. It 
appears that this remedy deserves a thorough trial in all cases prior to 
resorting to the knife and more especially in cases in which the disease 
is so extensive as to preclude the possibility of complete removal by 
local measures. 

Other forms of general treatment in actinomycosis are of no avail, 
and all local measures, short of complete removal of the infected tissues, 
result in more harm than good, as they often give rise to secondary 
infection with pus-microbes, which always aggravates the local conditions 
and hastens a fatal termination. In cases where a radical operation is 
out of question on account of the extent of the disease or the importance 
of organs involved in the process, parenchymatous injections of a 2-per- 
cent, solution of boric acid, a l-to-1000 solution of corrosive sublimate, 
or a l-to-1500 solution of nitrate of silver might be tried ; but, on the 
whole, such injections have little influence in arresting the local exten- 
sion of the disease. Kottnitz recommends very highly cauterization 
with solid stick of nitrate of silver in actinomycosis of the skin and soft 
parts in which suppuration and formation of fistulous tracts have taken 
place. He reports four cases of actinomycosis of the head and neck 
treated successfully by the use of this remedy. Dr. McGovern, of Wis- 



612 PRINCIPLES OF SURGERY. 

consin, also reports a successful case. It appears that this caustic pos- 
sesses a specific destructive action on the actinomyces. The surgical 
treatment of actinomycosis, before suppuration has occurred, consists in 
the excision of the infected tissues in all cases where such a procedure is 
practicable. The incision should be carried some distance, at least \ to 
1 inch, from the visible granulations, with a view of removing not only 
the inflammatory tissue, but also the minute invisible foci in its imme- 
diate vicinity. If, after the excision, suspicious tissue is found in the 
wound, this should be removed by a careful dissection with forceps, 
knife, and scissors, or destroyed by using the actual cautery. Acids and 
other chemical caustics should not be relied upon in destroying the 
infected tissues. An actinomycotic abscess should be treated on the 
same principles as a tubercular abscess. The abscess-cavity is freely 
exposed by laying open the fistulous openings, and the granulation tissue 
is removed with a sharp spoon. Undermined skin is cut away with 
scissors. If the disease has extended to bone, this is also thorough!}- 
scraped, and it is a good plan, after the cavity has beeii thoroughly irri- 
gated and dried, to cauterize the whole surface with the actual cautery. 
Such wounds should not be sutured, but packed with iodoform gauze, in 
order to keep the infected area readily accessible to inspection, so as to 
enable the surgeon at .each dressing to recognize a local recurrence. 
Should this occur, the same means are to be repeated in eliminating the 
infected tissues. As soon as the wound is covered with healthy granula- 
tions it ma}' be closed by secondary suturing, or, if this cannot be done 
on account of too great loss of skin-tissue, the defect is covered with 
large skin-grafts according to Thiersch's method. Repeated scraping 
operations will often succeed in finally eradicating the disease, provided 
the infected parts are accessible to vigorous curetting and the application 
of the actual cautery. 



CHAPTER XXIV. 

Anthrax. 

Synonyms : Contagious carbuncle ; charbon ; Milzbrand ; malignant 
pustule ; wool-sorters' disease. The mj-colog}' of anthrax is better under- 
stood than that of any other microbic disease. The bacillus of anthrax 
is the largest of the known pathogenic microbes, and ever since it was 
discovered it has been a favorite subject of investigation in every labora- 
tory and by every bacteriologist. 

HISTORY. 

As a disease among animals, anthrax has been known since the 
earliest records of history. The contagiousness of this disease has been 
recognized since the beginning of the eighteenth century. During the 
first part of the present century it was described as a blood disease. 
Heusinger, in his classical work, " Die Milzbrand Krankheiten cler Thiere 
und des Menschen " (Erlangen, 1850), declared anthrax to be a malarial 
neurosis. In the year 1855 Pollender published his discoveries, which 
inaugurated a new era in the study of anthrax. As early as 1849 he 
discovered, in the blood of cattle suffering from anthrax, a mass of innu- 
merable, fine, rod-like bodies, which appeared to be of a vegetable nature 
and resembled vibriones. Branell found the same rods in the blood of 
men, horses, and sheep which had died of anthrax. He also detected 
the same bodies during life in the blood of the diseased animals. Dela- 
fond regarded this parasite as a variety of leptothrix. In 1863 appeared 
the work of Davaine, wherein he pronounced these rods to be bacteria, 
and later he called them bacteridia. He believed them to be the essential 
cause of anthrax, as the disease could not be found in blood that did not 
contain them. Through the labors of Pasteur, Koch, Nsegeli, Bollinger, 
and others, the bacterium found so constantly in the blood and tissues 
of anthracic animals finally found a permanent place as the bacillus 
anthracis among the schizomycetes. 

The first reliable and positive accounts of the disease in man we owe 
to Fournier, Montfils, Thomassin, and Chabert, who published their de- 
scription of the disease between the years 1769 and 1780. Fournier first 
distinguished the spontaneous and the communicated carbuncle of man. 
The primary existence of anthrax in man was asserted b}' Bayle in 1800 
and by Davy la Chevrie in 1807. 

(613) 



614 PRINCIPLES OF SURGERY. 

DESCRIPTION OF THE BACILLUS OF ANTHRAX. 

Non-motile rods, 5 to 10 micro-millimetres long and 1 to 1.25 micro- 
millimetres broad, and threads made up of rods and cocci. 

The rods, as a rule, are straight ; only when they grow to a con- 
siderable length and meet with resistance they become slightly curved. 
The rods and threads are round, and, with their threads truncated at 
right angles, appear as though they had been cut off obliquely. The 
interior, as long as fission does not proceed, is perfectly homogeneous, 
and absorbs aniline dyes very readily and uniformly. The development 
of spores in long, undivided threads, as we find them in fluid culture 
media, takes place at regular intervals, where we find them as bright, oval 
spots that become more and more apparent, marking the direction of the 
rods. Upon solid culture media the development of spores is preceded 




v o - o 
o Bo to 




Fig. 170.— Anthrax Bacilli. Spore Formation and Spore Germination. 

{Koch.) 

A. From the spleen of a mouse after twenty-four hours' cultivation in aqueous humor. Spores 
arranged in rods like a string of pearls. X650. B. Germination of spores. X650. C. The same 
greatly magnified. X 1650. 

by transverse segmentation of the rods. The cell-membrane of each 
section finally becomes the membrane of the spore, each pole of the 
spore presenting a small mass of protoplasm that can be stained. 

(a) Staining. — Cover-glass preparations of fluid specimens can be 
stained with a watery solution of any of the aniline dyes. They can be 
rapidly stained with a drop of fuchsin or gentian-violet, but more satis- 
factorily by floating the cover-glass for twenty-four hours. The prepara- 
tions are dried and mounted in Canada balsam. The spores are not 
stained by the ordinary methods. Tissue-sections containing bacilli are 
best stained by Gram's method, and after-stained with eosin or picro- 
carminate of ammonium. By double staining the rods are seen to 
consist of a hyaline sheath with protoplasmic contents. 

(b) Cultivation. — The bacillus of anthrax grows luxuriantly in di£ 



ANTHRAX BACILLI IN THE LIVING BODY AND THE SOIL. 615 



ferent fluid and solid nutrient media. Bouillon and aqueous humor of 
the eye furnish an excellent soil, but for inoculation purposes the cultures 
are now generally grown upon solid nutrient media. 

Gelatin. — If a nutrient medium containing from 5 to 8 per cent, of 
gelatin is inoculated, a whitish line develops in the track of the needle- 
puncture, and from it fine filaments spread out on the sides. 

In a more solid nutrient gelatin the growth appears only as a thick, 
white thread. The culture liquefies the gelatin, and 
the growth subsides as a white, flocculent mass. 

Plate Cultures. — Cultures upon a sloping sur- 
face of solid nutrient agar-agar or gelatin form a 
viscous, snow-white plaque. 

Without access of air the culture does not 
grow, the bacilli being aerobic. 

Potato. — Inoculation of sterilized potato yields 
a very characteristic growth. The deep chamber 
containing the potato is placed in the incubator, 
and in about thirty-six or forty -eight hours a 
creamy, very faintly yellowish layer forms over the 
inoculated surface, with, usually, a peculiar trans- 
lucent edge. On removing the cover of the damp 
chamber, a strong, penetrating odor of sour milk is 
emitted. 

MULTIPLICATION OF ANTHRAX BACILLI IN THE 
LIVING BODY AND THE SOIL. 




Fig. 171.— Stab Cul- 
ture of Anthrax 
Bacilli in Gelatin, 
Grown at Room-Tem- 
perature (16° to 18° C.) . 
Four Days Old. Natu- 
ral Size. 

(Baumgarten.) 



In the body of living animals the bacilli 
multiply exclusively by segmentation, and never 
produce spores. Spores are produced only in dead 
nutrient media, and under certain conditions only, 
among which a proper temperature is the most im- 
portant factor. The limits of the temperature 
vary between 12 to 18° C. and 43° C. ; at a temperature of less than 
12° C. growth of the rods and spore production no longer take place. 
Pasteur's assertion that bacilli and spores in the cadavers of buried 
animals are active when brought to the surface by earth-worms is im- 
probable. The disease, according to Koch, is spread among animals 
by germinating spores which attach themselves to plants and grass in 
swamps and along river-banks, and which, when taken in with the food, 
become the cause of intestinal anthrax. 

Schrakamp and Friedrich are of the opinion that bacilli can 
multiply in the superficial layer of the soil, while Kitt maintains 



616 



PRINCIPLES OF SURGERY. 



that fructification of the bacilli takes place in the manure deposited 
in pastures. 

INOCULATION EXPERIMENTS. 

In order to cause death of animals by inoculation with the bacillus 
of anthrax, a pure culture or anthracic blood must be injected into the 
subcutaneous tissue or into the circulation, or the virus may be trans- 
mitted by inhalation or by feeding. Goats, hedgehogs, mice, sparrows, 
cows, horses, guinea-pigs, and sheep can be readily infected. Rats 
are less susceptible. Pigs, dogs, cats, white rats, and Algerian 
sheep are immune. Frogs and fish have been rendered susceptible to 
anthracic infection by raising the temperature of the water in which they 





Fig. 172.— Anthrax Colony upon Gelatin. X80. (Muegge.) 
A, after twenty-four hours ; B, after forty-eight hours. 

lived. Koch produced the disease artificially in rabbits and mice by 
injecting a drop of anthracic blood, with the result of producing death 
usually within twenty-four hours. After death sections taken from 
different organs, stained in metlrvl-violet with carbonate of potash, were 
examined under the microscope, and the bacillus was found in great 
abundance in all of them. When magnified fifty diameters such prepara- 
tions present, at the first glance, an appearance as if a blue coloring- 
material had been injected into the vessels. Each intestinal villus is 
permeated by an exceedingly delicate blue net-work ; in the mucous 
membrane of the stomach all the capillaries surrounding the gastric 
glands are stained blue ; in the ciliary processes each projection is 
injected, and a spiral vessel stained of a dark-blue color leads from 



INOCULATION EXPERIMENTS. 



617 



thence to the iris and breaks up into a fine, blue net-work, with loops 
directed toward the edge of the iris. The liver and lungs and the 
glandular structures, such as the pancreas and salivary glands, are com- 
pletely permeated by the same blue, vascular net-work. Indeed, there is 
no organ which is not more or less injected with the blue mass. It is, 
however, very striking that this injection is only present in the capillary 
vessels. All the larger vessels, even the arteries and veins of an intes- 
tinal villus, are either not at all stained or have but a light-blue streak in 
their interior, and that only here and there. When magnified 250 times 
one can see that the blue capillary net-work is composed of numerous 
delicate rods, and when a power of 100 diameters is used it is found that 




Fig. 173.— Intestinal Villus of Anthractc Rabbit. The Bacilli in Capillary 
Vessels Alone Stained. X250. {Koch.)* 

the apparent injection is nothing more or less than the bacillus anthracis, 
stained dark-blue, and present in incredible numbers in the whole 
capillary system. 

In the other vessels, especially in the larger ones, often only a single 
bacillus may be met with at long intervals, or they may be quite absent. 

The distribution of the bacillus in the capillaries is not, however, 
quite uniform. There are fewer in the brain, in the skin, in the capil- 
laries of the muscle, and in the tongue than elsewhere; on the other 
hand, in the liver, lungs, kidneys, spleen, intestines, and stomach the} r 
are always present in enormous numbers. In the capillaries themselves 

* Copied from "Traumatic Infective Diseases," by permission of the New Sydenham 
Society, London. 



618 PRINCIPLES OF SURGERY. 

the bacilli accumulate in largest numbers at the point most distant from 
the nearest afferent artery and the efferent vein, — that is, at points where 
the blood-current is slowest. Where the bacilli are present in greatest 
abundance it not unfrequently happens that the capillaries become 
torn, and blood with the contained bacilli is extravasated. This occurs 
most frequently in the glomeruli. Many of these burst, and the bacilli 
pass into the uriniferous tubules. In mice the spleen is more especially 
the seat of the bacilli ; then come the lungs and, last of all, the kidnej^s. 
Frisch inoculated the cornea in animals and produced a keratitis, caused 
by the bacilli, which multiplied with great rapidity, local dissemination 
taking place through the corneal spaces. 

INFECTION IN MAN. 

An intact skin furnishes ample protection against infection with 
bacilli or spores, but the slightest abrasion may become the necessary 
infection-atrium for either method of infection. Machnoff rubbed agar- 
agar cultures of anthrax bacilli mixed with a little lanolin into the shorn 
skin of rabbits and in every instance the animal died about the third day 
of acute general anthrax. The skin showed no microscopical lesions, 
but bacilli were found in the hair-follicles. The animals in which the 
same substance was simpfy applied to the skin did not contract the 
disease. During the act of rubbing the microbes are forced into the 
hair-follicles from which they enter the tissues and the general circula- 
tion. Infection may occur through a healthy mucous membrane, either 
with bacilli or spores. As the anthrax bacillus is a non-motile parasite, 
penetration of the epithelial lining can only occur by local growth of the 
bacillus. Spores are such minute structures that they can reach the 
circulation through a healthy raucous membrane in the same manner and 
by means of the same agencies as we have found necessary for the trans- 
portation of other minute foreign parasites from the mucous surface into 
the circulation. Ollivier reports the case of a baby, 5 months old, sup- 
posed to have a severe bronchitis. The chest yielded all the physical 
signs of bronchitis, but in addition there was some general oedema and 
an erythematous patch upon the upper left chest. After death, on the 
ninth day, the " pustules" were found in the bronchi. In this case infection 
was caused by the entrance of bacilli or spores through the bronchial 
mucous membrane. In another case, reported by Bouisson, infection 
evidently occurred through the mucous membrane of the intestinal 
canal. During life the diagnosis made was intestinal obstruction. The 
autopsy showed great congestion of the intestines ; the mesenteric 
glands were greatly enlarged. One loop of the intestine was greatly 
swollen, and a thrombus twenty centimetres long was found in the im- 



PLATE V. 







Bacillus Anthracis. From a Section of Kidnef of a Mouse Gram's 
Method and Eosin. Zeiss T \ o.l, Oc. 2. (After Grookshank.) 



ATTENUATION OF VIRUS AND PROPHYLACTIC INOCULATIONS. 619 

mediate neighborhood. In this case bacilli were found in the blood. In 
man infection frequently takes place through a small wound or abrasion 
in persons handling the infected products of anthracic animals, such as 
wool, hair, and hides. In other instances, insects, such as mosquitoes 
and flies, that have fed on the blood of living anthracic animals or the 
dead tissues of animals that died of the disease, may become disease- 
carriers. The sting of such an infected insect may communicate the 
disease with the same degree of certainty as an intentional inoculation 
with a drop of anthracic blood or a minute quantity of a pure culture. 

INTENSIFICATION OF VIRUS. 

While it is known that some chemical substances exert an attenuating 
influence on the virulence of the anthrax bacillus, it has also been found 
that an attenuated virus will again become more virulent by adding 
certain substances. It must, therefore, be taken for granted that the 
chemical composition in which the bacillus is suspended influences, in one 
way or the other, its virulence. It has been found, for instance, -that the 
addition of a minute quantity of lactic acid to a fluid containing the 
bacillus in an attenuated form greatly intensifies its virulence within a 
very short time. Thus, Arloing, Cornevin, and Thomas found that the 
pathogenic power of a fluid containing these bacilli, to which g J^ part 
of lactic acid had been added, and the mixture allowed to stand for 
twenty-four hours, was increased twofold ; if, then, a little water, con- 
taining a very easily fermentescible sugar, is added to the mixture, and 
another twenty-four hours allowed to elapse, the virulence attains its 
maximum, and frogs inoculated with this virus die in from twelve to 
fifteen hours ; whereas, when inoculated with ordinary virus, they live 
from forty to fifty hours. Kitt has repeated and confirmed these experi- 
ments. 

ATTENUATION OF VIRUS AND PROPHYLACTIC INOCULATIONS. 

By cultivating the bacillus of anthrax in neutralized bouillon at 
42° to 43° C. (107.6° to 109.4° F.) for about twenty days, the infecting 
power is weakened, and animals inoculated with it are protected against 
the disease. A still greater degree of immunit}' is obtained by inoculat- 
ing a second time with material that has been less weakened. Animals 
thus treated are then protected against the most virulent form of anthrax, 
but only for a time. A temperature of 55° C. (131° F.), or treatment 
with 1- to 5-per-cent. solution of carbolic acid, deprives the bacilli of 
their virulence. The virulence of the bacillus is also altered by passing 
it through different species of animals. Woolbridge secured immunity 
against anthrax in animals by cultivating the bacillus in an alkaline 



620 PRINCIPLES OF SURGERY. 

solution at a temperature of 37° C. (98.6° F.) for two days. At this 
time the fluid was filtered and a small quantity of the filtrate injected 
into the subcutaneous tissue of rabbits ; these rabbits remained well, and 
subsequently resisted injection of most virulent anthracic blood. 

Hankin, under the guidance of Koch, at the Hygienic Institute of 
Berlin, isolated an albuminose from anthrax cultures, which, when in- 
jected into rabbits and mice in small quantities, rendered these animals 
immune against the most virulent cultures. The albuminose was pre- 
pared from the cultures by precipitation with absolute alcohol ; the 
precipitate was well washed in this liquid to free it from toxins, — 
since it is known that all such substances are soluble in alcohol. After 
the addition of alcohol it was filtered off and dried, then redissolved 
and filtered through Chamberland's filter. Four rabbits were inoculated 
with virulent anthrax spores, and 3 of them received an injection of 
albuminose into the ear-vein at the same time ; the latter recovered, while 
the remaining animal not thus protected died, in about forty-eight hours, 
of anthrax. In another experiment, 10 mice were each injected with the 
millionth part of their body-weight of anthrax albuminose and with 
active vaccine at the same time. Of these 3 died after 108 to 116 hours; 
the others recovered. Three others had only the two-millionth part of 
their bodj'-weight of anthrax albuminose and active culture. Two of 
them survived. Four control mice were inoculated, and all died of 
anthrax. He has come to the conclusion that when a large dose of albu- 
minose is injected into an animal the entrance of anthrax bacilli into the 
system is aided, and when a small dose is administered immunity is 
acquired against its poisonous properties, protecting the animal against 
subsequent inoculations with active cultures. It has been recently 
shown, by the experiments of Ogata and Jasuhara, that when the bacil- 
lus of anthrax is cultivated in the blood of an immune animal, its patho- 
genic power is modified so that it no longer kills susceptible animals, 
and may be used as a protective vaccine material. Prophylactic inocu- 
lations of sheep with mitigated virus is carried on upon an extensive 
scale in France b}^ Pasteur and his pupils, and recent statistics bearing 
upon their value in protecting the animals against anthrax have shown 
them effective in preventing the spread of the disease in infected 
districts. 

More recent bacteriological investigations have shown that an antag- 
onistic action exists between the bacillus of anthrax and other patho- 
genic microbes, notably the diplococcus pneumoniae, the streptococcus 
of erysipelas, the staplrylococcus pyogenes aureus, and the bacillus pro- 
digiosus. Experiments have shown that the growth of anthrax may be 
retarded or destroyed entirely, according to the quantity of the antag- 



CLINICAL VARIETIES OF ANTHRAX. 621 

onist injected. This discovery will result in additional resources in 
effecting immunity and open a new field in the treatment of this disease. 

CLINICAL VARIETIES OF ANTHRAX. 

Primary bronchial and pulmonary anthrax, caused by the inhalation 
of dust containing bacilli or spores, and primary anthrax of the intes- 
tines, caused by eating anthracic meat or by drinking water infected 
with spores, are diseases that are occasional^ met with in man ; but, as 
these affections belong to the physician and not to the surgeon, the 
student should consult any of the modern text-books on the practice of 
medicine to become familiar with their symptomatology. 

Buchner has studied experimentally the entrance of the anthrax 
bacillus through the intact mucous membrane of the bronchial tubes. 
The bacillus and spores were administered b}^ inhalations, in the shape 
of dry powder, and suspended in steam. On examining the bronchial 
mucous membrane at different stages, under the microscope, it was seen 
that the spores were transformed in a very short time into bacilli, and 
that the latter, by their growth, pushed themselves between the cells and 
into the capillary vessels. It was observed that, the greater the pulmo- 
naiy irritation, the more the passage of the microbes was retarded. The 
entrance of the bacilli from the surface of the mucous membrane into 
the capillary vessels was seen to depend on an active process. 

Secondary anthracic bronchitis, pneumonia, and enteritis are met 
with in almost all cases of localized anthrax followed b}' secondary 
general infection. Primary intestinal anthrax in man was studied by 
Wahl, Recklinghausen, Buhl, Wagner, Bollinger, Leube, and Frankel, 
and all of these authors succeeded in demonstrating the presence of the 
essential microbic cause in the inflamed mucous membrane. When the 
microbe enters the body through the mucous membrane of the gastro- 
intestinal canal with the food or drink, it gives rise to a primary anthrax 
of the intestinal canal, that again rmvy become general by metastatic dis- 
semination through the systemic circulation. Localization upon the 
mucous surface first takes place upon the most prominent part of the 
valvulse conniventes on the mesenteric side of the bowel, and from here 
the infection spreads over the entire surface. Vierhoff has collected 41 
cases of anthrax intestinalis, the total number found reported up to 1885. 
The author himself observed 2 cases of secondaiy intestinal anthrax in 
the hospital at Riga. Cases of secondary intestinal anthrax — that is, 
localization of the bacillus of anthrax in the mucous membrane of the 
intestinal canal after external infection — were known to the older authors, 
while observations of primary localization in the digestive tract date 
only from the middle of the last century. As soon as general infection 



622 PRINCIPLES OF SURGERY. 

has taken place, the diffusion throughout the capillary system is the 
same as has been described under the head of Inoculation Experiments. 
The forms of anthrax that concern the surgeon most are those which 
result from infection of the external surface by the introduction of the 
bacilli or spores through a small wound, abrasion, or the sting of an 
infected insect. The favorite location for the development and growth 
of the anthrax bacillus in man and beast is in the connective tissue ; it 
is, therefore, immaterial in what manner the microbe reaches this tissue, 
as localization here marks the beginning of the disease. The clinical 
forms vary according to the localization of the disease, its extent, and 
the intensity of the infection. Most all authors follow Bollinger's classi- 
fication, according to which all cases are brought under one of the follow- 
ing varieties : 1. Anthrax acutissimus, or apoplectiformis. 2. Acutis. 
3. Subacatis. 

The primary location of the disease is in accordance with the manner 
in which infection has taken place. W. Koch states that in animals and 
man the bacillus can enter the organism through one of the following 
routes : (a) through the skin ; (b) gastro-intestinal canal ; (c) respiratory 
passages. 

Anthrax of the External Surface. — Infection of the subepidermal 
connective tissue can only occur through a defect in the epidermis ; 
hence, every anthrax of the external surface corresponds in its location 
with an infection-atrium, through which the essential microbic cause has 
entered the connective tissue. The bacillus of anthrax, when brought 
in contact with living tissue susceptible to its pathogenic action, causes 
an acute inflammation characterized by grave alterations of the capillary 
wall and rapid exudation. The microbe first multiplies at the primary 
point of invasion, and, if it does not meet with sufficient tissue resist- 
ance, it enters the blood-vessels and causes general infection, which always 
proves fatal. Infection occurs most frequently in exposed parts of the 
body; thus, of 63 cases of anthrax in man, collected by Slessarewskji, 
the disease showed itself 6 times on the face, 21 times on the neck, and 
36 times in other places. Trousseau relates that in Paris 20 persons 
were attacked with anthrax in ten years, and in all of them the source 
of infection could be traced to horse-hair imported from South America. 
The pathologico-anatomical conditions vary according to the primary 
seat of invasion, the structure of the organ, and seat of the disease. 
The first tissue changes are observed at the point of inoculation. From 
a prognostic and pathological point of view external anthrax can be 
divided into two distinct varieties: 1. Anthrax pustule. 2. Anthrax 
oedema. 

I. Anthrax Pustule. — This is the so-called malignant pustule. It is 



CLINICAL VARIETIES OF ANTHRAX. 623 

usually met with in parts not covered by clothing, as the fingers, hands, 
and face. The only case of anthrax pustule that has come under the 
observation of the writer occurred in the palm of the hand in the person 
of a robust butcher. The base of the pustule attained the size of a silver 
dollar and was very hard. The surface of the pustule sloughed, leaving 
a granulating surface which healed slowly under antiseptic treatment. 
This form of the disease is determined by the anatomical structure of 
the part affected, which must be dense and vascular. The pustule begins 
as a small, red point that resembles the bite of a flea, in the middle of 
which a small vesicle appears, which, at first, contains a transparent 
serum, and, later, becomes sanguineous. The patient complains of an 
itching, burning sensation. The skin around the centre of the pustule is 
at first slightly raised by the inflammatory infiltration underneath it. 
Within twenty -four or forty-eight hours the size of the infiltrated area is 
as large as a nickel, and the inflamed part presents all the evidences of a 
very acute circumscribed inflammation. The swelling is now painful, 
tender on pressure, and exceedingly firm to the touch. The centre, pre- 
viously occupied b}^ a vesicle, is of a brownish-red or blackish-gra}^ color, 
and presents indications of approaching gangrene. The epidermis ex- 
foliates, exposing a necrosed area the size of a pea to a silver half dollar. 
The dead tissue remains firmly connected with the surrounding indurated 
parts, until it becomes gradually detached in the course of the suppurative 
inflammation, which ensues sooner or later. After separation of the 
slough, spontaneous healing may take place, always leaving a depressed 
scar. In this form of anthrax general infection seldom occurs, as the 
infection remains local, the early and abundant inflammatory exudation 
forming an impermeable wall around the infected zone, be} T ond which the 
bacilli cannot escape. General infection, however, in such cases occa- 
sionally takes place where a vein becomes implicated in the process, and 
general infection is not prevented by the formation of a plastic thrombus 
on the proximal side of the intra-venous culture. The acuteness of the 
inflammation, and probabty, also, the direct necrotic effect of the toxins 
of the bacilli, invariably result in necrosis of the central portion of the 
pustule, which is the most characteristic pathological and clinical feature 
of this form of anthrax. 

2. Anthrax CEdema. — This form of anthrax follows infection, if the 
tissues around the infection-atrium are freely supplied with loose con- 
nective tissue and the blood-supply to the part is scanty, — conditions 
which are present about the e} T elids, neck, and forearm. Anthrax in 
these localities appears as a flat infiltration without well-defined borders, 
and with little or no discoloration of the skin. In a case of this kind 
that came under my care the primary infection occurred in the temporal 



624 PRINCIPLES OF SURGERY. 

region above the external ear. The patient was a cattle-dealer about 40 
years of age. The oedema spread very rapidly, and with the local ex- 
tension the septic symptoms increased proportionately. Death at the 
end of the second week was preceded by symptoms indicative of internal 
sepsis. From the infiltrated tissues a rapidly-spreading oedema extends 
in all directions. This form of anthrax is attended by greater danger 
of general infection than anthrax pustule, as the bacilli are less effectu- 
ally walled in by the inflammatory product. Vesication, exfoliation of 
cuticle, and gangrene may also take place, and in milder cases a spon- 
taneous cure is possible. As long as the infection remains local general 
symptoms are absent, but as soon as general infection has occurred the 
symptoms point to progressive septicaemia. 

PATHOLOGY AND MORBID ANATOMY. 

If the tissues of a primary anthrax of the external surface are 
examined under the microscope, all the appearances of an acute non- 
suppurative inflammation are shown. The specific effect of the bacillus 
on the tissues results in serious alteration of the capillary vessels, which 
gives rise to an abundant inflammatoiy exudation. In malignant pust- 
ule, or anthrax pustule, the para-vascular and connective-tissue spaces 
become completely blocked with leucocytes in a remarkably short time, 
and necrosis of the central portion of the inflammatory product is a 
constant result of the acute ischaemia and the speedy coagulation necrosis 
thus produced. Anthracic inflammation never terminates in suppura- 
tion unless secondaiy infection with pus-microbes takes place. The local 
oedema in the oedematous variety, at the point of infection, is caused by 
vascular disturbances due to the presence of the bacilli within the blood- 
vessels and the interstitial inflammatory exudation caused tty their pres- 
ence. In fatal cases the necropsy reveals the same changes in different 
organs as Koch has described in his experiments on rabbits. The capil- 
lar}^ vessels in every part of the body will be found completely or par- 
tially blocked with bacilli, but the number of microbes is always greatest 
in the most vascular organs, as the spleen, liver, and kidneys. 

The bacilli, as in mice-septicaemia, will be found in the capillary ves- 
sels arranged in the direction of the blood-current, and most numerous 
where the flow of blood is most impeded, as at points of intersection. 
General infection always takes place through blood-vessels. The inter- 
nal organs are found enlarged and exceedingly vascular from engorge^ 
ment caused by the capillary obstruction. Minute extravasations are 
found in different organs where the bacilli are most numerous, resulting 
in complete destruction of the capillary wall and rhexis. The secondary 
intestinal affection most frequently assumes the form of inflammatory 



PATHOLOGY AND MORBID ANATOMY. 



625 



hemorrhagic infiltration, more seldom that of hemorrhagic catarrh; 
ulcerations the size of a split pea to 2 inches in diameter are frequently 
present, the remaining portion of the mucous membrane showing well- 
marked evidences of acute inflammation, great vascularity, and infiltra- 
tion. Mesenteric glands are swollen and contain numerous bacilli. The 
bronchial and intestinal mucous membranes show all the appearances of 
recent inflammatory changes, great vascularity, slight thickening, and 
here and there minute extravasations. In some cases the meninges of 
the brain show well-marked lesions that account for the cerebral symptoms 




during life 



tew 

Fig. 174.— Anthrax. Section from Liver. X 700. (Fluegge. ) 

Pathologists have often failed in locating the immediate 
cause of death in fatal cases of anthrax, and various theories have been 
advanced at different times to determine this point. 

In the most virulent form, the anthrax acutissimus, Bollinger be- 
lieves that the rapid growth of the bacillus in the blood brings about a 
sudden diminution of oxygen and a surplus of carbonic acid, and that 
death takes place by a slow process of asphyxia. Against this theory 
it can be maintained that, in the blood of animals that have died of the 
acutest form of the disease, comparatively few bacilli are found ; and, 
further, that in the experiments made by Nencki, on the blood of rabbits 

40 



626 PRINCIPLES OF SURGERY. 

that had died of this form of anthrax, it was found as capable of oxy- 
genation as the blood of healthy animals. The theory that death results 
from purely mechanical causes due to the presence of bacilli tn great 
abundance in the blood-vessels is likewise not tenable, because no such 
fatal degree of obstruction in the capillary circulation has been found 
at the post-mortem examinations. As a third hypothesis, Bollinger 
advanced that the bacillus may generate a chemical poison that may 
cause death by intoxication. In reference to the last-mentioned cause, 
Hoffa calls attention to the following three possibilities : — 

1. The bacilli of anthrax are in themselves poisonous, and the in- 
crease in their number increases the quantity of the poison in the same 
ratio. Against this supposition the results of the experiments made by 
Hoffa himself furnish the most conclusive proof. Of a pure culture of 
anthrax bacilli he injected a large quantitj^ directly into the jugular veins 
of rabbits. The animals thus infected showed no symptoms of acute 
intoxication, but died in the same manner as animals infected in the 
usual way. 

2. The bacilli of anthrax produce a poison capable of causing fer- 
mentation in the blood ; this poison is soluble in the blood. The fact 
that filtered blood of animals that had died of anthrax did not produce 
toxic symptoms when injected into healthy animals speaks against this 
argument. 

3. The bacillus of anthrax separates toxic substances from complex 
combinations in the organism. This last explanation appears, from 
analogy of the views that are now entertained of bacteria and toxins, 
to be the most plausible, and he made an effort to produce such sub- 
stances outside of the animal bodj r , upon artificial culture media. For 
this purpose he cultivated the bacillus with the greatest precautions 
upon sterilized meat kept for several weeks in an incubator at 37° C. 
(98.6° F.). The chemical product thus obtained he attenuated according 
to the methods advised by Stass-Otto, Brieger, and after the more recent 
method of Fischer. 

By the methods of Stass-Otto and Fischer he succeeded in pro- 
ducing a substance that possessed an alkaline reaction, and produced 
toxic effects in animals. A strictly-pure article and an accurate chemical 
description of it could not be obtained, on account of the smallness of 
the quantity produced. The substance produced by Stass-Otto's method 
was used in experimenting on frogs, mice, guinea-pigs, and rabbits; both 
of them produced symptoms of intoxication. After a short period of 
intoxication, with increased action of the heart and accelerated respira- 
tion, the animals became somnolent ; respirations deep, slow, and irregu- 
lar, assisted by the action of all accessor}' muscles of respiration ; pupils 



DIFFERENTIAL DIAGNOSIS. 627 

dilated, temperature normal, diarrhoea, faeces bloody ; speedy death. At 
the necropsy the heart was found contracted, the blood was of a dark 
color, and ecchymosis of the pericardium and peritoneum existed. There 
were no microorganisms in the blood. The pathological conditions 
described here are an accurate duplication of the post-mortem descrip- 
tion in fatal cases of anthrax. The same author succeeded subsequently 
in isolating, by a complicated process, a toxic substance from the bodies 
of anthracic rabbits with the formula C 3 H 6 N 2 , which he called anthracin, 
besides a small quantity of methyl-guanidin. To the former substance 
he attributes the toxic symptoms in cases of anthrax. Injected subcu- 
taneously in rabbits, it produced first restlessness, rapid pulse, and 
accelerated respiration, followed by somnolence, deeper and slower respi- 
ration, diarrhoea, asphyctic symptoms, convulsions, and death. This 
substance is closely allied to kreatin, and contains 23 per cent, of 
nitrogen. These experiments leave but little doubt that the fatal termi- 
nation in cases of anthrax is caused by the action of toxic substances 
formed in the body in consequence of the action of the bacilli upon 
certain as yet unknown combinations in the organism. 

DIFFERENTIAL DIAGNOSIS. 

Anthrax must be distinguished from other forms of acute circum- 
scribed inflammation, notably from furuncle and carbuncle. A furuncle 
is conical from the beginning, and the summit is transformed into a 
small slough. A carbuncle is nothing more nor less than a multiple 
furuncle, and is produced by the same microbic cause. Anthrax develops 
from a single centre, and the infiltration proceeds from this point in all 
directions. Necrosis is preceded by vesication, and the black, necrosed 
tissue is fully exposed after exfoliation of the epidermis. The cedema- 
tous form of anthrax might be mistaken for erysipelas or acute phlegmo- 
nous inflammation. Anthrax oedema is usually not attended by much 
discoloration of the skin, and there is no such distinct and abrupt line of 
limitation as in erysipelas. Phlegmonous inflammation, when advanced 
to the extent where it may resemble anthrax oedema, has gone on to the 
stage of suppuration. The differential diagnosis between malignant 
oedema and anthrax can only be made by searching for the primary cause 
by the use of the microscope. A positive differential diagnosis between 
suppurative lesions and anthrax can be made in the course of one or two 
days by inoculation experiments. If a rabbit or mouse is infected with 
a drop of anthracic blood or serum taken from the centre of the inflam- 
matory product, death from anthrax will follow within two daj^s ; while 
the same amount of fluid taken from a suppurative depot will produce 
no effect, or, at most, only a circumscribed abscess. As the anthrax 



628 PRINCIPLES OF SURGERY. 

bacillus can be readily stained and identified under the microscope, a 
positive differential diagnosis between these affections can always be 
made by the use of the microscope. 

PROGNOSIS. 

The location of the disease, the character of the tissues primarily 
affected, and the general condition of the patient greatly influence the 
prognosis in cases of anthrax. The prognosis is most favorable in young, 
healthy individuals suffering from anthracic pustule, as in such instances 
the general strength of the patient and the active tissue proliferation at 
the seat of infection are well calculated to prevent general infection ; 
while, in persons debilitated from any cause affected with the ©edematous 
variety, general infection is very liable to follow. An anthrax oedema 
of the hand or arm is a less serious condition than a similar affection of 
the face or neck. As a general rule, it may be stated that, the firmer and 
more circumscribed the local lesion, the more favorable the prognosis, 
and vice versd^ the more extensive the area of infection and the more 
diffuse the cedeina, the greater the danger to life from general infection. 
The occurrence of general infection may be recognized without difficulty 
by the general symptoms, which indicate the existence of progressive 
septic infection. The bacillus of anthrax multiplies with great rapidity 
after its entrance into the circulation, and the anthracin, which produces 
the septic symptoms, is elaborated in amounts proportionate to the 
number of bacilli in the body. Fever, cough, rapid respiration, feeble and 
rapid pulse, diarrhoea, and delirium are some of the symptoms indicating 
that the disease has become general. All hope of recoveiy must be 
abandoned as soon as general infection has occurred ; death from pro- 
gressive infection and intoxication will be certain to take place, in spite 
of the most heroic local and general treatment. 

TREATMENT. 

The surgical treatment of anthrax must be directed toward the 
elimination or neutralization of the primary microbic cause. As within 
the living body the reproduction of the primary cause takes place ex- 
clusively by segmentation of the bacilli, any germicidal agents that 
inhibit or destixty the pathogenic property of the bacilli will be found 
useful in the local treatment of anthrax. It has been found experiment- 
ally that a 5-per-cent. solution of carbolic acid will arrest the growth 
of anthrax cultures, and clinical experience has demonstrated that the 
same solution, when brought in contact with the infected tissues by 
parenchymatous injections, has a decided influence in arresting further 
extension of the infection. 



TREATMENT. 629 

Lande reports 2 cases of malignant anthrax saved by parenchyma- 
tous injections of carbolic acid. In the first case, a man aged 27, the 
upper lip was the seat of the disease ; in the second, a woman aged 65, 
the anthrax occupied the region below the scapula. Both patients were 
very ill, low delirium and other symptoms of toxaemia being present. 
The injections were made into the subcutaneous tissue around the 
pustule. The strongest solution used consisted of 15 grammes of 
neutral glycerin and an equal part of distilled water, in which 3 grammes 
of pure carbolic acid were dissolved. The injections were made at five 
points around the pustule, and represented a total dose of 50 centi- 
grammes of the acid. The injections caused considerable pain, but 
rapid improvement followed. The solution used — 10 per cent. — was 
stronger than any previously emplo}ed for the same purpose by Bceckel, 
Raimbert, and others. A 5-per-cent. solution in ordinary cases is strong 
enough, but in grave cases the 10-per-cent. solution must be used until 
improvement takes place, which should occur within foiir-eight hours. 
Potiejenko has tried the parenchymatous injections of a 10-per-cent. 
solution of carbolic acid in four exceedingly severe cases of anthrax, and 
has obtained a complete cure in all of them. Three or four syringefuls 
of the solution were injected into the swelling and its neighborhood once 
daily, the part being kept covered in the interval with compresses soaked 
in a 5-per-cent. solution of the same antiseptic. Amoldow speaks very 
highly of the treatment of anthrax by parenchimatous injections of 
corrosive sublimate dissolved in a 5-per-cent. solution of carbolic acid 
in the proportion of 2 grains to the ounce. The object of the parenchy- 
matous injections should be to saturate, as far as possible, all of the 
infected tissues with the antiseptic for the purpose of destroying the 
bacilli, and, at the same time, to permeate the surrounding healthy 
tissue for some distance, with a view of destroying the soil for the 
growth of the microbes in advance of the invasion. The surface over 
the entire infected area should be rendered thorough^ aseptic, in order 
to prevent secondary infection with pus-microbes through the needle- 
punctures. The punctures should be made a few lines from the border 
of infiltration, but always toward the centre of the infected district. 
The injection is made gradually as the needle is withdrawn, so as to 
saturate the tissues for some distance along the entire length of the 
track of the needle. At one sitting from four to twelve injections 
are made, according to the size of the anthrax and the urgency of the 
symptoms. A compress wrung out of a l-to-1000 solution of corrosive 
sublimate should be kept constanth T applied. Application of an ice-bag 
over the antiseptic compress will assist the germicidal agents in retard- 
ing or arresting further multiplication of the bacilli in the tissues. 



630 PRINCIPLES OF SURGERY. 

The injections should be repeated every six hours until the disease is 
under control, or until it is deemed unsafe, from the quantity injected, 
to administer more carbolic acid for fear of causing intoxication. Ex- 
cision has been objected to on the ground that the wound might become 
a new source of infection, and thus leave the patient in a more pre- 
carious condition, so far as general infection is concerned, than before 
the operation ; but such is not the case if the area of infection is limited 
and the incisions can be made through healthy tissue. The following 
case affords a good illustration of the value of excision of anthrax in 
well-selected cases : — 

Kaloff, of St. Petersburg, in making experiments with anthrax on 
animals, accidentally infected himself, either by a needle-puncture or by 
handling the organs of anthracic animals. The local infection appeared 
on the outer side of the thumb of the left hand as a small vesicle, which 
soon disappeared, but gave place to circumscribed infiltration on the 
second day. This inflammation rapidly extended, and was surrounded 
by hsemorrhagic vesicles. The indurated tissues were promptly removed 
by excision ; nevertheless, on the next da}', swelling of axillary glands 
on same side, fever, great prostration, also diarrhoea, set in. The skin in 
the axillary region and side of chest was much swollen and, at different 
points, bright-red, at others bluish red. One of the axillary glands, the 
size of a hen's Qgg, and glands along the margins of the pectoralis 
major muscle were removed and field of operation thoroughly disinfected 
with a 5-per-cent. solution of carbolic acid ; the same solution was also 
thrown into the surrounded tissues with an hypodermic syringe. Cessa- 
tion of fever and rapid healing of wound, followed by recovery. The 
diagnosis was confirmed by successful cultivations made with fragments 
of the excised tissue in bouillon and gelatin. Excision should always 
be resorted to in cases of anthrax pustule, as it fulfills the etiological 
indications more promptly and thoroughly than an}' other treatment. 
The incisions should be made outside of the indurated tissues, and, for 
the purpose of preventing traumatic dissemination of the disease, the 
surface, after thorough irrigation, should be brushed over with a 10-per- 
cent, solution of carbolic acid before the wound is sutured. This pro- 
cedure will destroy any bacilli that may have become deposited upon the 
surface of the wound. 

In the case just cited it is possible that lymphatic infection — an 
unusual occurrence in anthrax — developed in consequence of the entrance 
of bacilli into the open lymphatic vessels on the surface of the wound. 
Excision under strict antiseptic precautions is also justifiable in anthrax 
oedema, even if all of the infected tissues cannot be removed, as sterili- 
zation of the remaining portion of the infected tissues can be secured 



TREATMENT. 631 

subsequently more efficiently by parenchymatous injections than if the 
primary focus of infection is allowed to remain as a hot-bed for pro- 
gressive infection. In such cases it would be good practice to sear the 
whole surface of the wound with the actual cautery, for the purpose of 
preventing general and regional dissemination by the entrance of bacilli 
into the open lumina of veins and lymphatics, and also to increase the 
resisting capacity of the tissues to infection by exciting an active tissue 
proliferation. The actual cautery would prove successful in recent cases, 
in cutting short an attack, if resorted to before any considerable infiltra- 
tion has occurred. It is said that shepherds, in districts where anthrax 
is endemic, destroy the vesicle with a red-hot needle as soon as it is 
detected, and it is seldom that the infection does not yield to this treat- 
ment. At this early stage the whole area of infection is limited, and 
could be most effectually destroyed with the sharp point of a Paquelin 
cautery. The general symptoms in severe cases of local anthrax, and 
after general infection has occurred, resemble the clinical aspects of 
septicaemia produced by other causes, and patients suffering from general 
primary or secondary anthrax require the same stimulating, tonic, and 
supporting treatment that has been laid down in the treatment of 
septicaemia. 



CHAPTER XXV. 

Glanders. 

Synonyms : Farcy ; equinia ; malleus humidus ; Morve ; Rotzkrank- 
heit. A contagious disease characterized by multiple foci of inflamma- 
tion and suppuration, and caused by infection with a specific microbe, — 
the bacillus mallei. The disease originates in the horse and occurs in 
men by contagion. Although glanders in man is a rare affection, it pre- 
sents, from a bacteriological study, so many points of interest that it 
merits more than a passing notice. It is one of the infectious diseases 
whose microbic cause is now thoroughly understood. 

BACTERIOLOGICAL HISTORY OF THE DISEASE. 

That glanders in man occurred as an infection from the horse species 
of animals has been known for a long time. Its contagiousness among 
horses was asserted b}^ Solleysel in the seventeenth century. Rindfleisch 
believed that he saw vibriones in the granular contents of glanderous 
abscesses. Klebs detected, in cultures of pus taken from animals suffer- 
ing from this disease, small rods and granules, but cultivations and 
inoculations in rabbits failed. The presence of minute organisms in 
cases of glanders was pointed out by Christatt and Kiener in 1868, and 
their observations were corroborated by Bouchard, Capi tan, and Charrin, 
who found the organisms not only in parts exposed to the air, such as 
nasal ulcerations and pulmonary abscesses, but also in parts not so 
exposed, such as the spleen, liver, and lymphatic glands. Chaveau 
demonstrated by his experiments that the virus of glanders was fixed to 
small, solid particles, as he found the sediment, which formed after di- 
lating pus with water, active. This discovery marked an advance in the 
knowledge of the physical nature of the virus. Loffler and Schiitz are 
the discoverers of the bacillus of glanders in horses. In 1882 they made 
a preliminary report of their researches (Deutsche Med. Wochenschrift, 
1882, No. 52). In 1886 Loffler published his elaborate monograph on 
this subject ("Die JEtiologie der Rotzkrankheit," Arbeiten aus dem 
Kaiserlichen Gesundheitsamte zu Berlin, Bd. i, pp. 141-199). About 
the same time, 0. Israel made cultures upon blood-serum from nodules 
of three glanderous horses, with which he produced the disease artificially 
in rabbits. The bacilli contained in these cultures correspond with the 

(632) 



DESCRIPTION OF BACILLUS MALLEI. 633 

description of those isolated by Scliiitz and Loffler. Soon after Ldffler's 
first paper appeared, Bouchard, Capitan, and Charrin published almost 
simultaneously the results of their researches and observations ; but it 
appears from Loffler 's second paper that none of them had been able to 
produce a pure culture. Kitt and Weichselbaum were the first who, by 
their own investigations, were able to corroborate the correctness of 
Loffler's discovery : the former by his observations and experiments on 
animals, the latter by a case of glanders in the human subject that came 
under his own observation. 

DESCRIPTION OF BACILLUS MALLEI. 

According to Loffler, the bacillus of glanders appears as a small rod, 
which is somewhat shorter and broader than the tubercle bacillus ; its 
length varies but little, and corresponds to about two-thirds of the di- 
ameter of a red blood-corpuscle ; the thickness varies between one-fifth 
and one-eighth of its length. It is a non-motile, aerobic microbe. 

These bacilli are either straight or slightly curved and rounded at 
W/V'WiVK^iifl their ends. Usually, they are found in pairs in a 
fyf/^itfrJI^h parallel direction, held together by a delicate, unstained 
ijwftfjfihjifyth pellicle. Examined in a drop of fluid, they show active 
tw/ltL^ll\\y<2y^/f molecular movements. Spontaneous movements could 
Fig. 175. -Bacilli n0 ^ he observed by Loffler. The colorless and some- 
a F yotjn£ E potato times even somewhat dilated portions of the stained 
?BaunSarten ) X 95 °" bacillus are n °t spores, but, as Loffler affirms, indica- 
tions of commencing death. Loffler found that bacilli 
kept in a dry state for three months could occasionally be made to 
grow, but in most instances, after a few weeks, they could no longer be 
cultivated, which fact speaks against the existence of spores. On the 
other hand, in favor of the presence of endo-spores must be regarded the 
results obtained by Rosenthal, in Baumgarten's laboratory, with Neisser's 
method of staining spores, who showed that at least some of the bacilli 
contain spores, while in others the points which refuse staining material 
are undoubtedly, as Loffler claims, evidences of vacuolar degeneration. 

(a) Staining. — The method of staining the bacilli of glanders is 
characteristic ; when the bacilli are treated by basic and aniline dyes no 
effect is produced. 

Method of Schiitz. — The sections are placed for twenty-four hours 
in the following mixture: Potash solution (1 in 10,000), concentrated 
alcohol, methylene-blue solution, — equal parts. Wash the sections in a 
watch-glass with water acidulated with 4 drops of acetic acid. Transfer 
for five minutes to 50-per-cent. alcohol, clarify in clove-oil, and mount in 
Canada balsam. 



634 PRINCIPLES OF SURGERY. 

Lbffler's Method. — Sections are immersed for a few minutes in a 
solution of potash (1 in 10,000), then for a few minutes in an alkaline 
solution of metlryl-blue ; after which they are decolorized with a solution 
of tropseolin in acetic acid, or, what is still better, in a fluid composed 
of 10 centimetres of distilled water, 2 drops of sulphuric acid, and 1 
drop of a 5-per-cent. solution of oxalic acid. 

(b) Cultivation. — When cultivated on solid sterilized blood-serum at 
a temperature of 38° C. (100.4° F.), the growth appears in the form of 
minute transparent drops on the surface, which consist exclusively of the 
characteristic bacilli. Cultures upon boiled potato, according to Loffler, 
Kitt, and Weichselbaum, form in three days a uniform amber-yellow 
layer, that about the sixth to the eighth day assumes a reddish hue, resem- 
bling the color of oxide of copper, which is not easily mistaken for any 
other culture upon the same soil. Upon this nutrient medium the bacilli 
were cultivated through twelve generations, and the cultures retained 
their activity for a }^ear ; whether the bacillus was capable of cultivation 
after this time is not mentioned. The temperature at which cultures could 
be made to grow varied from 30° to 40° C. (86° to 104° F.). The bacillus 
also grows in neutralized bouillon, with and without the addition of pep- 
tone. The culture first renders the fluid turbid, and, later, settles on the 
bottom of the vessel as a white, shining mass. Weichselbaum succeeded 
in growing the bacillus upon ordinary nutrient agar and gelatin. Ras- 
kina rendered these nutrient media more fertile for the growth of this 
microbe by the addition of chicken-natron albuminate. Kranzfeld suc- 
ceeded best with Nocard and Roux's mixture, — meat-peptone, glycerin, 
agar-agar. 

TENACITY OF BACILLUS MALLEI. 

Loffler ascertained that this bacillus shows the same degree of re- 
sistance to heat and germicidal substances as other bacilli without spores. 
The bacillus is destroyed by exposure for ten minutes to a temperature 
of 55° C. (131° F.). It is also destroyed by a 3- to 5-per-cent. solution 
of carbolic acid in five minutes, and in two minutes in a l-to-5000 solu- 
tion of corrosive sublimate. 

INOCULATION EXPERIMENTS. 

Kitt enumerates the following animals as being susceptible of inocu- 
lation with the virus of glanders : Tiger, lion, cat, sheep, goats, guinea- 
pigs, horse, ass, rabbits, and white rat. Pigs, dogs, the common rat, 
ducks, and chickens possess great immunit}^ ; the inoculations at best 
produce only a slight local reaction. Loffler made his first experiments 
on guinea-pigs and the field-mouse. In the guinea-pigs he observed, 
three to five days after subcutaneous injection of a pure culture, an ulcer 



INOCULATION EXPERIMENTS. 



635 



at the point of inoculation, and at the end of the first week swelling of 
the nearest lymphatic glands, attended by suppuration. At this stage 
of the disease the process often came to a stand-still and the animals 
recovered. In many animals the disease progressed quite rapidly to a 
fatal termination. Abscesses were frequently found in the testicle and 
the epididymis in the male, and in the breast and external genital organs 
of the female. The face, nasal cavity, and ankle-joint were also fre- 
quently the seat of ulcerative processes. In case the disease proved 



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Fig. 176.— Glanderous Nodule from the Liver of a Field-Mouse. 
Bismarck-Brown Staining. Bacilli Stained after Loffler's 
Method. Bacilli Magnified and Drawn Twice this Size. X250. 
(Baumgarten. ) 

K, karyokinetic figures in. epithelioid cells. 



fatal, death usually occurred three or four weeks after inoculation. At 
the post-mortem, aside of the affections enumerated, nodules were found 
in the spleen, lungs, and frequently in the liver. The histological struc- 
ture of a recent nodule bears a great resemblance to tubercle. The 
bacilli are always found more numerous in the nodules if the disease is 
produced artificially by inoculation. The inflammatory product is first 
composed almost exclusively of epithelioid cells, between which leuco- 
cytes from the periphery insinuate themselves. Giant cells are never 



636 PRINCIPLES OF SURGERY. 

found in glanderous nodules ; the epithelioid cells are derivatives of con- 
nective tissue and endothelial cells ; while the leucocytes escape from the 
inflamed capillary vessels. Baumgarten constantly observed karyokinetic 
figures in the epithelioid cells. 

The leucocj^tes that enter the nodule soon show evidences of frag- 
mentation, and are converted into pus-corpuscles. The bacilli are dis- 
tributed among the cellular elements singly, in pairs, and in groups. 
Some of them may be seen also within the cellular elements, especially 
the epithelioid cells. 

Field-mice proved a great deal more susceptible to the virus of 
glanders than guinea-pigs, as they usually died three or four days after 
inoculation. The necropsy in these animals showed, at the point of 
inoculation, an infiltration from which swollen lymphatic vessels led to 
the nearest lymphatic glands. In the spleen and liver, which were always 
found greatly enlarged, numerous small nodules could be seen, while the 
remaining internal organs presented a normal appearance. Glanders in 
guinea-pigs and field-mice presents a series of pathological changes that 
cannot be mistaken for any other affection. The bacilli of glanders in 
the different organs can be detected most readily in recent specimens. 
In the blood bacilli were detected only in very acute cases, — a circum- 
stance that explains why so many inoculations with the blood of glan- 
derous horses proved unsuccessful. The bacilli of glanders are evidently 
strictly tissue- and not blood- parasites. 

Lundgren took a nodule from the lungs of a horse that had died of 
glanders, and implanted fragments of it under the skin of rabbits. The 
animals died about the nineteenth day after inoculation, and the necropsy 
revealed induration and small abscesses at the point of infection, and 
small, yellow nodules in the spleen, liver, lungs, testicles, and mucous 
membrane of the nose. Implantation of spleen-tissue into other rabbits 
fixed the period of incubation in this animal at from eleven to twelve 
days. 

Kranzfeld has recently published the results he obtained by inocula- 
tions with the virus of glanders in an animal hitherto not subjected to 
experimentation of this kind. He procured a pure culture from a nodule 
of a man who had died of glanders after a brief illness. Inoculations 
were made in a small rodent which is very numerous in the southern 
part of Russia, the Spermophilus guttatus. The course of the disease in 
this animal was almost the same as in the field-mice that were used by 
Lofner. Of 28 animals infected with different cultures, 16 died on the 
fourth day, 9 on the fifth, 2 on the seventh, and 1 on the tenth. The 
post-mortem appearances were always characteristic : a greenish-gray 
infiltration at the point of inoculation and a number of nodules in the 



GLANDERS IN THE HORSE. 637 

spleen; in one animal also very small, white nodules in the liver. Culti- 
vations from these nodules yielded a pure growth of the bacillus of 
glanders. If animals are infected by direct injection of a pure culture 
into a vein, no serious symptoms are produced; but, if soon thereafter 
one or more muscles are injured subcutaneously, the microbes escape 
through the lacerated vessels, localize at the seat of injury, and produce 
a grave form of the disease. It has been determined by experiment that 
the farther from the trunk the inoculations are made, the less intense is 
the local reaction. When an animal is inoculated at a distance from the 
trunk, and shows no general symptoms, a subcutaneous injury of any 
portion of the trunk will furnish the necessary conditions for the 
development of a local form of infection. 

It had been generally believed that the intact skin furnished an 
adequate protection against infection with the bacillus of glanders until 
shown very recently by the experiments of Babes and Nocard that infec- 
tion can take place through the healthy skin. Nocard rubbed a pure 
culture of the bacillus into the skin in two guinea-pigs, and found on the 
fifteenth day some of the hair-follicles the seat of glanderous inflamma- 
tion. Histological examination showed numerous bacilli in the follicles, 
the epithelial layer much thickened, and the surrounding connective 
tissue in a state of proliferation. The infection had extended from the 
follicles through the connective tissues into the lymphatic vessels 
underneath, as was evident from the presence of bacilli in the lymphatic 
glands, vessels, and connective-tissue spaces in the immediate vicinity 
of the primary lesion of the skin. 

GLANDERS IN THE HORSE. 

Glanders and farcy in the horse are different manifestations of the 
same disease, and, as each of them is divided into an acute and chronic 
form, we find described four varieties of the disease in this animal, — 
acute and chronic glanders, acute and chronic farcy. 

Acute Glanders. — This form of glanders is attended by a high tem- 
perature (106° to 109° F.) and other S3'mptoms of acute sepsis, and 
proves uniformly fatal in a few days. The breathing is accelerated, the 
pulse feeble and rapid, and there is complete loss of appetite. The nasal 
mucous membrane, at first of a dark, coppery color, with dark-red ecch\ T - 
motic patches, becomes purple ; these eccl^moses are rapidly converted 
into ulcers, from which issues a copious sero-sanguinolent discharge. 
Lymphatic infection is a characteristic feature of acute glanders. The 
submaxillary and cervical glands enlarge and suppurate, discharging 
unhealth}' -looking, ichorous pus. Abscesses also form in the lymphatics 
of the face. 



638 PRINCIPLES OF SURGERY. 

Chronic Glanders. — This is the form most commonly seen in the 
horse. The disease begins in the mucous membrane of the nose. Small, 
whitish nodules, composed of small, round cells, are formed in the 
mucous membrane. These nodules soften and ulcerate. Similar nodules 
may be found in the larjmx, trachea, and bronchi. The ulcerations may 
remain superficial, or they may extend to the deep tissues, even attacking 
cartilage and bone. The internal organs, especially the lungs, may 
become the seat of metastatic foci. The left nostril appears to be 
affected more frequently than the right. The lymphatic glands under- 
neath the lower jaw enlarge very rapidly, often reaching considerable 
dimensions during a single night. The glandular swellings may continue 
for several da} T s, afterward slowly disappear, and then re-appear as 
rapidly as before. The discharge from the nostrils presents a starchy 
or glue-like appearance, adheres to the mucous membrane, where it dries 
and accumulates, causing narrowing of the nasal opening. 

Acute Farcy. — Acute farcy, together with chronic farcy, is simply 
another manifestation of glanders, and is initiated in a very similar 
manner to acute glanders. There are the same lesions of the lymphatics 
and nodules, and abscesses are found in the skin. A general swelling of 
the cutaneous tissues takes place, varying in size for a time, but suddenly 
a number of distinct swellings or nodules will appear, termed " farcy 
buds." These specific nodules, so characteristic of farc} r in either its 
acute or chronic form, involve the skin, subcutaneous connective tissue, 
or they imi/y extend to the deeper tissues. The}^ vary in size from a pea 
to a hazel-nut. These nodules suppurate, and, after evacuation of their 
contents, leave ragged ulcers that discharge a foul, grayish-white, creamy 
liquid tinged with blood. When several ulcers are in close proximity 
they may become confluent and form an extensive ulcerating surface. 
With the appearance of the nodules the lymphatics become inflamed, 
swollen, and indurated. Not infrequently acute farcy terminates in the 
development of acute glanders, with all the pathological conditions that 
have been described as characteristic of that disease, thus showing their 
etiological identity. 

Chronic Farcy. — In this form of glanders the lymphatic glands are 
principally involved. The disease is not attended by much febrile dis- 
turbance, and all of the other general symptoms are less marked than in 
the other varieties of glanders. The lymphatic glands become enlarged, 
and nodules are formed in the skin, lungs, and other viscera. Central 
softening and suppuration of the nodules is a regular occurrence. Long, 
fistulous tracts often result from extensive undermining of the skin. In 
all of these different forms of glanders in the horse the cause remains 
the same, and the pathological conditions are identical; only the clinical 



GLANDERS IN MAN. 639 

aspects vary from the location, intensity, and extent of the primary 
infection. 

GLANDERS IN MAN. 

In man the disease occurs in an acute and chronic form, but does 
not exactly resemble any of the varieties of the disease in the horse or 
the disease artificially produced in animals by inoculation. The discharge 
from the nostrils of a diseased horse, brought in contact with an abraded 
surface or a mucous membrane, will communicate the disease. Nocard 
made experiments to determine whether the bacillus of glanders could 
enter the intact skin. He rubbed a pure culture of the microbe into the 
skin of 3 asses and 15 guinea-pigs. Of the 18 animals only 2 guinea-pigs 
were infected, and it is probable that, in these, infection occurred through 
minute excoriations of the skin. Notwithstanding the positive results 
that followed the cutaneous inoculations in guinea-pigs with a pure cult- 
ure of the bacilli of glanders by Nocard, it is, for all practical purposes, 
safe to make the assertion that the virus of glanders can only find 
entrance into the organism through a wounded surface. Whether in- 
fection ma} 7 " not take place through the alimentary canal has, so far, not 
been definitely ascertained. It is certain that the disease cannot be con- 
tracted by eating boiled or fried flesh of animals. Infection through the 
respiratory organs is possible, as cases have been reported in which the 
lungs were the primary and only seat of the disease. The fact that man 
can be infected with a pure culture of the bacilli of glanders as success- 
fully as the animals that have been successfully experimented on received 
a sad illustration five years ago in Yienna. 

Dr. Hoffman, a young and promising plrysician, who was making 
some experimental investigations on animals with pure cultures, accident- 
ally inoculated himself with the needle used for making the inoculations, 
and died from acute glanders in a few days. Observations of veterinary 
surgeons and experimental researches have shown, conclusively, that the 
disease can be transmitted from the mother to the foetus in utero by 
passage of the bacilli through the placenta from the maternal into the 
foetal circulation. When man is the subject of glanders, bacilli are found 
more constantly in the blood than in glanderous animals. In the case 
described by Weichselbaum, numerous bacilli could be seen in the blood. 
In this case a thrombus was found in one of the large meningeal veins, 
containing numerous bacilli, and which, undoubtedly, was one of the 
sources of the bacilli in the circulation. In man the nasal mucous mem- 
brane is not so frequently affected as in animals, although Bollinger has 
shown that in horses the nasal cavity is not always affected, and that it 
may present a normal condition, even when the larynx and lungs are 
seriously affected. Muscular abscesses, that may simulate rheumatism, 



640 PRINCIPLES OF SURGERY. 

are of very frequent occurrence, especially in the chronic form of the 
disease. 

SYMPTOMS AND DIAGNOSIS. 

The symptomatology of glanders is variable, as it is greatly modi- 
fied by the intensity of the infection, the primary location of the disease, 
and the number and distribution of the metastatic foci. The disease 
may begin at a single point, and may then be mistaken for a carbuncle 
or a gangrenous erysipelas. Grsefe reports a case which began as an 
acute exophthalmos, and the nature of the disease was not ascertained 
until after death. In this case there were nodules in the choroid of the 
eye. Acute glanders runs a rapid and malignant course. Infection 
usually takes place through a small wound, puncture, or abrasion about 
the face or hands. At the point of inoculation a somewhat elongated, 
soft, inflammatory swelling or nodule forms in a few days. Central 
softening and suppuration soon transform the inflammatory product into 
an undermined ulcer, with irregular, ragged margins, surrounded by a 
wall of infiltration. In mild cases the disease may remain local, and the 
ulcer heals under proper treatment in a few weeks. In other cases 
regional infection takes place, and the lymphatic glands become swollen 
and suppurate, leaving the same kind of ulcers as at the primary seat of 
infection. 

In the fatal cases general infection takes place either through the 
veins or the tymphatic vessels, and the symptoms then resemble septi- 
caemia or pyaemia, or a combination of these two diseases, — septico- 
P3^83mia. If infection take place directly through the veins, a thrombo- 
phlebitis develops in connection with one of the nodules and the bacilli 
in the thrombus, which multiply in this nutrient medium and gain entrance 
into the general circulation singly or through the medium of infected 
emboli. Under such circumstances, nodules are found in the lungs, 
kidneys, and other internal organs, as suppurating metastatic deposits 
in muscles, bone, joints, and testicle. In such cases the general symp- 
toms may simulate to perfection typhoid fever, pyaemia, suppurative 
osteomyelitis, and acute general miliary tuberculosis. In acute cases 
where general infection occurs early and rapidly, death results in from 
one to three or four weeks, while in chronic cases the final fatal termi- 
nation is often postponed for months. In illustration of the clinical 
history of this disease I will quote briefly a few cases. 

A Russian medical journal of recent date states that a young 
soldier, who had been a wagoner before his admission into the army, was 
received into the military hospital suffering from two foul ulcers on the 
hard palate, which had perforated the nasal fossa and destroyed the 
inferior turbinated bones. Three weeks later a swelling appeared over 



SYMPTOMS AND DIAGNOSIS. 



641 



the e} T ebrow ; a fortnight afterward he complained of pain on the inner 
side of the left knee, around the internal tuberosity of the tibia. A 
purulent discharge occurred from the left ear, and, at the same time, an 
abscess developed on the back of the right hand which appeared as a 
deep-purple tubercle, with a hard circumference, and sunken toward the 
centre ; a purulent discharge oozed from the surface ; at first, for a 
short time after admission, the temperature varied, rising in the evening 
to 103° to 104° F. ; later on it fell to normal. The disease was mistaken 
for syphilis, and iodide of potassium was given without the least benefit. 
About ten weeks after admission he was in better health, and left the 
hospital, receiving his discharge from the army. Within a few weeks he 
returned, with extension of ulceration of the hard palate ; the uvula was 
destroyed. The characteristic nodules, the " farcy buds," appeared in 




Fig. 177.— Acute Glanders, involving Nose and Face, showing Ex- 
tent of Local, Lesions Eight Days after the Commencement of 
the First Symptoms. (Birch-Hirschfeld.) 



the face; the metastatic abscess on the back of the hand remained. The 
patient ultimately died of exhaustion. Before death some of the nodules 
were extirpated ; they were found to contain microorganisms resembling 
to perfection the bacillus of Loftier and Schiitz. 

Kuttner reports a number of cases in which the skin was the seat 
of numerous points of suppuration in the form of pustules, or more 
diffuse abscesses followed by ulceration. The disease has been mistaken 
more frequently for syphilis than any other affection. This mistake in 
diagnosis is very liable to be made in the chronic form, in which the 
nodules grow very slowly, are hard, and may occur in groups or like a 
string of beads. The nodules usually soften and form chronic ulcers, 
which closely resemble the ulcers resulting from the breaking down of 
gummata. If the disease primarily attack the nasal cavity, the mucous 

41 



642 PRINCIPLES OF SURGERY. 

membrane presents hard nodules, and a copious discharge from the nose 
is present. In acute glanders affecting the nose and face, extensive 
destruction of tissue by the rapid breaking down of the nodules is one 
of the prominent clinical features of the disease. Complete destruction 
of the nose, with formation of large ulcers of the face, may happen in 
the course of a week. 

Chronic glanders ma}' also be easily mistaken for tuberculosis of 
the skin, mucous membranes, and lymphatic glands. Acute glanders may 
simulate furuncle, carbuncle, and other acute suppurative lesions, as well 
as lymphangitis and erysipelas. In making a differential diagnosis be- 
tween these different affections and glanders, it is important, if possible, 
to trace the infection to its proper source. If the clinical history point 
to the possibility of infection by contact with a glanderous horse, it 
should be remembered that the period of incubation in man varies from 
two days to three weeks. A positive diagnosis must necessarily rest on 
the detection of the specific microbe in the granulation tissue or in the 
discharges, and the results obtained b} r inoculation experiments. The 
method of inoculation as an aid in diagnosis, proposed by Strauss, is of 
great value. This consists in the injection of cultures or of the sus- 
pected crude products into the peritoneal cavity of a male guinea-pig. 
If the disease is glanders a positive diagnosis can be made within three 
or four days. At the end of this time the scrotum is red and glossy, the 
cuticle desquamates, and suppuration occurs. The bacillus of glanders 
can be found in the pus. The animal usually dies in the course of twelve 
to fifteen days. When the animal is killed three or four clays after the 
inoculation suppuration of the testicle and its envelopes can be demon- 
strated, and the bacillus of glanders is invariably present in the products 
of the suppurative inflammation. As soon as general infection has taken 
place, the S3 T mptoms resemble pyaemia or septicaemia ; so that a dif- 
ferential diagnosis between metastatic glanders and general infection 
with pus-microbes cannot be made without the aid of the microscope and 
inoculation experiments. 

PATHOLOGY AND MORBrD ANATOMY. 

The bacillus of glanders resembles, in its immediate action on the 
tissues, both the bacillus of tuberculosis and the pus-microbes. The 
histological change first observed in the infected tissues is a transforma- 
tion of mature into embryonal tissue, the microscopical picture, with the 
exception of the absence of giant cells, resembling tubercle ; but this stage 
is of short duration, as the pyogenic effect of the bacillus of glanders 
soon produces purulent softening by the speedy conversion of the embry- 
onal cells and leucocytes into pus-corpuscles. The formation of abscesses 



PROGNOSIS. 



643 



is a constant occurrence, wherever localization has taken place, either by 
direct infection, secondary infection from regional diffusion through the 
lymphatic vessels and connective-tissue spaces, or by general infection 
by embolic diffusion through the general circulation. 

As soon as the disease has become general, the clinical picture and 
pathological conditions are the same as in p3'aemia caused by a suppu- 
rative lesion. The differentiation between the two forms of metastasis 
can be made only by demonstrating the primary cause, by use of the 
microscope or by the results obtained from inoculation experiments. 
The pus found in glanders is grayish red in color, and quite tenacious in 
recent lesions, but after opening the abscesses it assumes the character of 
ordinary pus, as the abscess-cavities then become the seat of secondary 
infection with pus-microbes. Swelling and abscesses of the testicles have 
been frequently observed in cases where the disease has become general, 




Fig. 178.— Section of a Glanders Nodule, x 700. (Fluegge.) 

the affection in these organs being one of the clinical manifestations 
that embolic dissemination has occurred. Primary glanders of the lungs 
from inhalation of the microbes into the air-passages gives rise to symp- 
toms and pathological conditions that cannot be distinguished from pul- 
monary tuberculosis, unless the essential cause can be demonstrated in 
the sputa under the microscope, or glanders can be artificially produced 
by the injection of sputum into the subcutaneous tissue or the peritoneal 
cavity of guinea-pigs. The pulmonary nodules soften and suppurate, 
and cavities form in the same manner as in pulmonary tuberculosis. 



PROGNOSIS. 

The prognosis in glanders should always be guarded, as a limited 
local lesion may be followed by a fatal form of general infection. The 
prognosis is comparatively favorable if the infection remain limited to 



644 PRINCIPLES OF SURGERY. 

a circumscribed area accessible to direct surgical treatment. It must be 
more guarded if regional infection through the lymphatic vessels has 
occurred, and it is absolutely fatal in cases of primary glanders of im- 
portant internal organs, and when general infection has followed in the 
course of a local lesion with or without regional dissemination. In the 
local form of the disease the ulcerations usually prove inveterate to 
treatment, and final recovery is often retarded for months by extensive 
undermining of the skin. Acute glanders with general infection, as a 
rule, proves fatal within one to three weeks, and death occurs in conse- 
quence of septic infection. 

TREATMENT. 

The prophylactic treatment consists in preventing infection from 
glanderous horses and substances which have become contaminated with 
the specific virus from diseased animals, and requires early recognition 
of the disease and killing of the affected animals, as well as thorough 
disinfection of the premises occupied by the diseased beast. The ca- 
davers should be cremated or deeply buried. Abrasions or granulating 
surfaces that have been exposed to infection should be cauterized. 

In cases of primary pulmonary or intestinal glanders, and after 
general infection from a local form of the disease has occurred, the 
treatment must be necessarily symptomatic, as such cases are beyond 
the reach of local or general treatment. The embarrassed respiration 
and feeble and rapid pulse indicate the use of alcoholic stimulants. A 
primary nodule should be removed by excision, taking all necessary pre- 
cautions to prevent infection of the wound in case the skin has been 
destroyed by ulceration. Limited regional infection should be treated 
in the same manner if ulceration has not taken place, and the conditions 
are such that all of the infected tissues can be removed with safety. 

Gold reports two cases of glanders in man cured by mercurial 
inunctions. In one of these cases sixty-two inunctions were made. He 
states that he has observed about thirty cases of glanders, and that, with 
the exception of the two treated by this method, all proved fatal. All 
subcutaneous abscesses were duly opened and washed out with a l-to-500 
solution of corrosive sublimate. All ulcers were similarly disinfected 
with the lotion, then painted with nitric acid and dressed antiseptically. 
The total quantity rubbed into the patient in the course of sixty-five 
days amounted to 1 pound, 1 ounce, and 3 drachms of mercurial ointment. 

After multiple abscesses have formed a radical operation is no 
longer indicated, the extent of the affection precluding the possibility 
of removing all of the infected tissues. In such cases the abscesses 
should be freely incised, fistulous tracts laid open, undermined skin cut 



TREATMENT. 645 

away, and, as far as possible, the infected tissues removed with a sharp 
spoon; then the entire surface should be disinfected with a 12-per-cent. 
solution of chloride of zinc. No attempt should be made, under such 
circumstances, to obtain healing of the superficial wounds until it be- 
comes apparent that the specific microbic cause has been eliminated or 
destroyed, and several repetitions of the curetting and disinfection may 
become necessary until this object is realized. The scraped surfaces 
should be kept covered with a moist antiseptic compress gauze, wrung 
out of l-to-2000 solution of corrosive sublimate or a 2-per-cent. solution 
of carbolic acid. If the prolonged use of these antiseptics is objection- 
able on account of danger from absorption of toxic doses of these drugs, 
strong iodine-water can be used in the same way. The internal use of 
iodine, creasote, and arsenic has been recommended as specific in the 
treatment of glanders, but clinical experience has not supported this 
claim, and the surgeon must rely upon local measures in his efforts to 
protect the patient against the dangers arising from regional and general 
infection ; while he must aim, at the same time, to maintain the resisting 
power of the tissues to the microbic invasion by a supporting tonic and 
stimulating treatment. 



INDEX. 



Abnormal and defective callus, 56 
Abscess, 229 
acute, 231 

diagnosis, 233 

treatment, 234 
chronic, 236 

diagnosis, 237 

treatment, 237 
iliac, 487 
lumbar, 487 
of brain, 300 

cerebral localization, 303-307 

prognosis, 301 

symptoms and diagnosis, 301 

treatment, 302 
of internal organs, 288 
of lung, diagnosis, 316 

exploration, 317 

operation, 317 
psoas, 487 
tubercular, 484 

pathological anatomy, 484 

prognosis, 488 

symptoms and diagnosis, 487 

treatment, 489-493 
Absolute asepsis, 23 
Accurate suturing, 25 
Achromatin, 8 
Actinomycosis hominis, 591 
clinical varieties, 598-605 
description of fungus, 592-595 
history, 591 
of brain, 607 

of bronchial tubes and lungs, 605 
pathology and morbid anatomy, 596 
prognosis, 610 
sources of infection, 595 
symptoms and diagnosis, 608 
treatment, 611 
Action of bacteria on tissues of body, 150 
Acute glanders, 637 
suppuration, 226 
tetanus, 429 



Amputation in tuberculosis of joints, 564 
Anthrax, 613 

attenuation of virus, 619 

clinical varieties, 621 

description of bacillus, 614 

differential diagnosis, 627 

history, 613 

in living body and in soil, 615 

infection in man, 618 

inoculation experiments, 616 

intensification of virus, 619 

multiplication, 615 

oedema, 623 

of external surface, 622 

pathology and morbid anatomy, 624 

prognosis, 628 

prophylactic inoculations, 619 

pustule, 622 

treatment, 628 
Antiphlogistic treatment of inflamma- 
tion, 133 
Arterial blood-supply, defective, 179 
Arteries, ligation of, 179 
Arthrectomy in tuberculosis of joints, 

556 
Arthritis, suppurative, 288 
Ascites, tubercular, 519 
Asepsis, 23 

Aspiration in tuberculosis of joints, 555 
Attenuation of pathogenic bacteria, 151 
Atypical resection, 559 

Bacilli of putrefaction, 344-351 
Bacillus coli communis, 221 
Bacillus of anthrax, description of, 
614 
multiplication of, 615 
mallei, 632 

description of, 633 
tenacity of, 634 
pyocyaneus, 219 
pyogenes fcetidus, 218 
saprogenes, 344, 345 



(647) 



648 



INDEX. 



Bacillus tetani, 415 
toxins of, 421 
tuberculosis, 456 
cultivation, 458 
description, 456 

manner of infection and dissemi- 
nation, 505 
staining, 457, 458 
Bacteria, 142 

action of, on tissues of body, 150 

attenuation, 151 

classification, 142 

cultivation, 146 

death-point, 146 

elimination, 165 

fission, 144 

growth, 149 

immunity, 153 

inoculation experiments, 150 

localization, 157-162 

multiplication, 144 

outside of the body, 154 

presence of, in healthy body, 155 

putrefactive, 177 

secondary or mixed infection, 162- 

165 
specific, 174 
spores, 145 

therapeutic inoculation, 152 
transmission of, from parents to 
foetus, 167-170 
Bacteridia, 613 

Bacteriological causes of suppuration, 
204 
researches, 256-259, 288, 289, 309- 
311, 320-324, 332-340, 363-367, 
414-423, 497, 498, 526-528 
Bladder, tuberculosis of, 586 

prognosis and treatment, 588 
symptoms and diagnosis, 586 
Blood-corpuscles, red, 83 

white, 82 
Blood-plates, 84 
Blood-vessels, 41 
Blue pus, 225 
Bone, 52 
Bone ferrule, 61 
splint, 61 
suture, 60 
tuberculosis, 524 
artificial, 525 



Bone tuberculosis, clinical and bacteri- 
ological researches, 526 
means of differential diagnosis, 536 
pathology and morbid anatomy, 

528 
prognosis, 538 

symptoms and diagnosis, 534-536 
treatment, 539-544 
Brain-abscess, 300-309 
Brain, actinomycosis of, 607 

exploration of, 307 
Bronchial tubes and lungs, actinomy- 
cosis of, 605 

Callus, 56 
Capillary vessels, 80 
Cancer aquaticus, 194 
Carbuncle, 247 

diagnosis, 248 

treatment, 248 
Cartilage, 33, 119 
Catarrhal inflammation, 113 
Caustics producing necrosis, 181 
Cauterization of wound, 447 
Cavum Retzii, 232 
Cell division, 13 
Central nervous system, 66 
Chemical pyogenic substances, 207 
Chromatin, 8 

five phases of, 9 
Chronic circumscribed suppurative os- 
teomyelitis, 285 
pathological anatomy, 286 
symptoms, 286 
treatment, 286 

glanders, 638 

inflammation, 124 

suppuration, 227 

tetanus, 430 
Cicatrization, 19 
Classification of bacteria, 142 
Clinical forms of erysipelas, 404 

of septicaemia, 341-361 

of suppuration, 226 

of surgical tuberculosis, 481-504 
Coagulation necrosis, 189 
Cold producing necrosis, 181 
Color in gangrene, 185 
Condition of tissue in necrosis, 186 
Connective tissue, 41 
Cornea, 30, 116 



INDEX. 



649 



Corpuscle, third, 84 
Croupous inflammation, 114 
Cultivation of bacteria, 146 

Decubitus, 178, 194 

Detective arterial blood-supply, 179 

Diabetic gangrene, 193 

Diapedesis, 82, 100 

Diphtheritic inflammation, 115 

Direct causes of suppuration, 207-222 

transmission of bacteria, 167 

union of wounds, 3 
Disturbance of function, 104 
Division of cells, 13 
Dry gangrene, 192 

Elimination of gangrenous part, 187 

pathogenic bacteria, 165 
Elongation of tendon, 51 
Embolism, 373-378 
Emigration of leucocytes, 96 
Emphysema in gangrenous tissue, 185, 

192 
Empyema, 309 

after-treatment, 314 

multiple resection of ribs, 315 
thoracoplastic operation, 315 
bacteriological studies, 309 
diagnosis, 311 
prognosis, 311 
treatment, 312 
drainage, 314 
evacuation of pus and removal of 

membranes, 313 
incisions, 312 
irrigation, 314 
resection of rib, 313 
Encapsulation of necrosed tissue, 188 
Eudocranial suppuration, 292-300 
Epidermization, 22 

Epididymis and testicle, tuberculosis of, 
582 
symptoms and diagnosis, 584 
treatment, 584 
Epiphyseolysis, 264 
Epithelia, 35 
Epithelioid cells, 473 
Ergot the cause of gangrene, 181 
Ergotine a cause of gangrene, 198 
Erysipelas, 389 
bullosum, 404 



Erysipelas, clinical forms, 404-408 

cultivation, 391 

description of streptococcus erysipe- 
latosis, 391 

erythematosum, 404 

facialis, 407 

gangrenosum, 405 

history of microbic origin, 389 

inoculation experiments, 392 
for therapeutic purposes, 392 

manner of infection, 394 

metastaticum, 406 

migrans, 406 

prognosis, 408 

relation of, to puerperal fever, 397 
to phlegmonous inflammation and 
suppuration, 399 

symptoms and diagnosis, 401-404 

traumatic, 408 

treatment, 408 
Erysipeloid, 411 

Essential condition for growth of bac- 
teria, 149 
Excision of wound, 446 
Experiments, inoculation of bacteria, 

150 
Exploration of brain, 307 

of lung, 317 
External parts, gangrene of, 182 
Exudation, inflammatory, 96 

Fallopian tubes, tuberculosis of, 579 

symptoms and diagnosis, 581 

treatment, 581 
False joints, 56 

causes of, 58 
Farcy, acute, 638 

chronic, 638 
Fascia tuberculosis, 571 
Fermentation fever, 342 

symptoms and diagnosis, 343 
Fibrous tubercle, 477 
Fission of bacteria, 144 
Fistula, 254 

Five phases of chromatin substance, 9 
Fixed tissue-cells, 86 
Folliculitis, suppurative, 245 
Foot, perforating ulcer of, 198 
Fragmentation of nucleus, 12 
Function, disturbance of, 104 
Furuncle, 246 



650 



INDEX. 



Gangrene, caused by ergot, 181 

color in, 185 

diabetic, 193 

dry, 192 

elimination, 187 

hospital, 195 

line of demarcation, 187 

moist, 192 

of external parts, 182 

prognosis, 198 

progressive, 191, 192 

senile, 193 

swelling, 185 

symmetrical, 182 

treatment, 199-203 
Gangrenous tissue, emphysema in, 185 
Genito -urinary organs, tuberculosis of, 

578 
Giant cells, 470 
Glanders, 632 

acute, 637 

bacteriological history of, 632 

chronic, 638 

in the horse, 637 

in man, 639 

inoculation experiments, 634 

pathology and morbid anatomy, 642 

prognosis, 643 

symptoms and diagnosis, 640 

treatment, 644 
Glands, 62 

kidney, 64 

liver, 63 

lymphatic, 64 

spleen, 64 

testicle, 62 
Glans penis and urethra, tuberculosis of, 

582 
Gonococcus, 220 
Granulating surfaces, skin-grafting in, 37 

wounds, suturing of, 29 
Granulation tissue, 13 

vascularization of, 16 
Granulomata, 125 
Growth of bacteria, 149 

HEMORRHAGIC INFLAMMATION, 107 

Hsemostasis, 24 
Head tetanus, 430 
Healing of wounds, 2 
Heat producing necrosis, 180 



Histogenesis of suppuration, 204 

of tubercle, 468 
Histological structure of tubercle, 470 
Histology of tubercle, 466 
Histozym, 342 
Hospital gangrene, 195 
Hyaline tubercle, 478 
Hydrophobia, 436 

a microbic disease, 438 

causes, 440 

in the dog, 437 

pathology and morbid anatomy, 444 

prognosis, 444 

symptoms and diagnosis, 441 

treatment, 446-451 

cauterization of wound, 447 
excision of wound, 446 
palliative, 450 
prophylactic, 446 
inoculations, 447 

Icterus, hematogenous, 379 
Immediate or direct union of wounds, 3 
Incubation period of tetanus, 424 
Indirect causes of suppuration, 206 
Infection-atrium of bacillus tetani, 425 
Inflammation, 79, 172 
catarrhal, 113 
chronic, 124 
diphtheritic, 115 
hemorrhagic, 107 
histological elements in, 80 
interstitial, 107 
modification of, 105 
of mucous membranes, 113, 114 
of non-vascular tissue, 115 
of serous membranes, 108 
parenchymatous, 105 
prognosis, 129 
suppurative, 108, 113 
symptoms, 87-104 
symptoms and diagnosis, 127-129 
treatment, 131 

anodynes, 140 

antiphlogistic, 133 

antipjTetics, 138 

antiseptic fomentations, 137 

application of cold, 135 

counter-irritation, 140 

diet, 139 

elevation of inflamed parts, 135 



INDEX. 



651 



Inflammation, treatment, ignipuncture, 
141 
massage, 140 

parenchymatous injections, 132 
phlegmonous, 399, 404 
physiological rest, 135 
stimulants, 139 
tonics and alteratives, 139 
Inflammatory exudation, 96 

transudation, 103 
Inoculation experiments of bacteria, 150 

of tuberculosis, 459 
Inoculation-tuberculosis in man, 462 
Inoculations, prophylactic, 447 
Internal ear,- tuberculosis of, 493 
necrosis, 182 
organs, abscess of, 288 
Interstitial inflammation, 107 
Intestinal sepsis, 361 
Iris, tuberculosis of, 494 

Joints, tuberculosis of, 544 
etiology, 544 

pathology and morbid anatomy, 546 
prognosis, 553 

symptom and diagnosis, 549 
treatment, 554 

amputation, 564 

arthrectomy, 556 

aspiration, 555 

atypical resection, 559 

rest, 554 

subcutaneous evacuation, 555 

tapping and iodoformization, 555 

typical resection, 562 

varieties of, 547-549 

Karyokinesis, 8 
Karyolysis, 182 
Karyomytosis, 8 
Karyorhexis, 182, 191 

Large cavities, suppuration in, 288 
Leptomeningitis, suppurative, 296 
Leucocyte, 82, 470 

emigration of, 96 
Ligation of arteries in their continuity, 

179 
Liquefaction of necrosed tissue, 188 
Localization of bacteria, 157-162 
Loss of function in osteomyelitis, 264 



Lung-abscess, 316-318 

Lupus, tubercular nature of, 495-498 

Lymphatic glands, tuberculosis of, 505 

pathological histology and morbid 
anatomy, 507 

prognosis, 511 

symptoms and diagnosis. 508 

treatment, 512 
Lyssa nervosa falsa, 443 

Macrocytes, 471 

Malignant oedema, 338 

Mammary gland, tuberculosis of, 577 

Mastzellen, 54 

Metastatic suppuration, 379 

Microbe en chapelet, 363 

Microbic cause of tetanus, 424 

origin of erysipelas, 389 
of suppuration, 204 
of tuberculosis, 452 
Micrococcus gonorrhcese, 220 

pyogenes tenuis, 217 
Modification of inflammation, 105 
Moist gangrene, 192 
Mouth and tongue, tuberculosis of, 572 

pathology, 572 

symptoms and diagnosis, 574 

treatment, 575 
Mucous membrane, inflammation of, 113, 
114 

of intestines, tuberculosis of, 575 

suppurative inflammation of, 229 

transplantation of, 40 
Mummification, 186 
Muscles, 46 

non-striated muscular fibre, 46 

striated muscular fibre, 47 

suture of, 49 

tuberculosis of, 570 
Mj^eloplaques, 56, 471 

Necrobiosis, 191 

Necrosed tissue, liquefaction of, 188 

Necrosis, 171 

coagulation, 189 

encapsulation, 188 

etiology, 172-183 

general symptoms, 188 

internal, 182 

pathological and clinical varieties, 
189-203 



652 



INDEX. 



Necrosis, prognosis, 198 

symptoms, 183-188 

treatment, 199-203 

varieties of, 189-203 
Nerve suture, 72 

primary, 73 

secondary, 74 
Nerves, peripheral, 67 
Nervous system, central, 66 
Noma, 194 

Non-vascular tissue, 30, 115 
cartilage, 33 
cornea, 30, 116 

inflammation of, 115 
Nucleus, fragmentation of, 12 

Obstructed venous circulation, 180 

Odor of necrosed tissue, 186 

(Edema, malignant, 338 

Opening of the skull, 307 

Operation, thoracoplastic, 315 

Origin of suppuration, 204 

Osseous tuberculosis, cause of, 524 

Osteoklasts, 56 

Osteomyelitis, suppurative, 255 
early operations, 275 
intermediate operations, 277 
late operatious, 278 

Pachymeningitis, suppurative, 292 
Pain a symptom of necrosis, 183 

of osteomyelitis, 261 
Parenchymatous inflammation, 105 
Paronychia, 244 
Pathogenic bacteria, 142 

attenuation, 151 

classification, 142 

cultivation, 146 

death-point, 146 

elimination, 165 

immunity, 153 

inoculation, 152 

localization, 157-162 

multiplication, 144 

presence of, in healthy body, 155 

secondary or mixed infection, 162- 
165 

transmission of, from parents to 
foetus, 167-170 
Perforating ulcer of foot, 198 

of stomach and duodenum, 197 



Pericarditis, suppurative, 318 
Pericardium, incision and drainage, 319 

puncture and aspiration, 319 
Peripheral nerves, 67 
Peritoneum, tuberculosis of, 516 

bacteriological remarks, 516 

clinical studies, 517 

pathology and morbid anatomy, 518 

symptoms and diagnosis, 520 

treatment, 521-523 
Peritonitis, adhesive, 519 

fibrinoplastic, 519 

plastic and suppurative, 324 

suppurative, 320-331 
Phagocytosis, 120 

Phlegmonous inflammation, relation of 
erysipelas to, 399, 404 

with suppuration, 238 
Physiological rest, 26, 135 
Plasma rhexis, 191 
Platycytes, 473 
Progressive gangrene, 191 

with emphysema, 192 
Prophylactic inoculations, 447 
Proteus mirabilis, 346 

vulgaris, 345 

Zenkeri, 346 
ttomaines, 150, 212, 346-351 

of pus-microbes as a cause of sup- 
puration, 212 
Puerperal fever, relation of erysipelas to, 

397 
Pulse, after ligation of artery, 184 
Purulent infiltration, progressive, 241 
Pus, 222 

blue, 225 

corpuscles, 223 

microbes, 209-215 

description and specific action of, 

214 
ptomaines of, 212 

red, 225 

serum, 223 
Putrefactive bacteria, 177, 344 
Pyaemia, 362 

bacteriological and experimental 
researches, 363 

etiology, 367-378 

in rabbits, 364 

pathological anatomy, 382, 383 

prognosis, 382 



INDEX. 



653 



Pyaemia, symptoms and diagnosis, 378- 
381 
treatment, 384-387 
Pyogenic microbes as a cause of sepsis, 
340 
substances, chemical, 207 

Ray-fungus, 592 

Raynaud's disease, 182 

Red pus, 225 

Redness a symptom of osteomyelitis, 263 

Regeneration, 1 

of different tissues, 30 
Rest, physiological, 26 
Reticulum, tubercle, 474 
Rib, resection of, 313 
Ribs, multiple resection of, 315 

Sapr^emia, 344 

prognosis, 352 

symptoms and diagnosis, 351 

treatment, 352 
Senile gangrene, 193 
Senkungsabscess, 487 
Sepsis, intestinal, 361 

pyogenic microbes as a cause of, 340 
Septicaemia, 332 

bacteriological researches, 332 

clinical forms of, 341-361 

in mice, 333 

in rabbits, 335 

progressive, 354 
causes, 354, 355 
pathology and morbid anatomy, 

359 
prognosis, 358 

symptoms and diagnosis, 356 
treatment, 359, 360 
Septico-pyaemia, 387 

kryptogenetic, 387 

spontaneous, 387 
Serous membranes, inflammation of, 108 
Skin-grafting, 38, 39 
Skin transplantation, 37 

Hirschberg's method, 40 

Reverdin's method, 37 

Thiersch's method, 38 

Wolfe's method, 40 
Skin, tuberculosis of, 495 

pathology and morbid anatomy, 498 

prognosis, 502 



Skin, tuberculosis of, symptoms and 
diagnosis, 499 
treatment, 502-504 
Skull, opening of, 307 
Spaltpilze, 142 
Specific bacteria, 174 
Spores of bacteria, 145 
Staphylococcus cereus albus, 216 
cereus flavus, 216 
epidermidis albus, 216 
flavescens, 216 
pyogenes albus, 215 
pyogenes aureus, 215 
pyogenes citreus, 215 
Stomach and duodenum, perforating 

ulcer of, 197 
Strahlenpilz, 591 
Streptococcus erysipelatosis, 391 

pyogenes, 217 
Subacute suppuration, 227 
Suppuration, 204 
acute, 226 
bacterial causes and histogenesis of, 

204 
chronic, 227 
clinical forms, 226 
direct causes, 207-222 
endocranial, 292-300 
history of microbic origin, 204 
in large cavities, 288 
in wounds, 228 
indirect causes, 206 
metastatic, 379 
pus, 222 

relation of erysipelas to, 399 
subacute, 227 
Suppurative arthritis, 288 

bacteriological researches, 288 
symptoms and diagnosis, 289 
treatment, 290 
inflammation, 108, 113 

of mucous membrane, 113, 229-249 
leptomeningitis, 296 
symptoms and diagnosis, 298 
treatment, 299 
osteomyelitis, 255 
bacteriological and experimental 

investigations, 256 
causes, 259 

chronic circumscribed, 285-287 
diagnosis, 264 



654 



INDEX. 



Suppurative osteomyelitis, history of, 
255 
pathological anatomy, 268 
prognosis, 266 
symptoms, 261 
treatment, 270 
pachymeningitis, 292 
symptoms and diagnosis, 293 
treatment, 294 
pericarditis, 318 
peritonitis, 320 
bacteriological and experimental 

researches, 320 
causes, 325 
clinical and bacteriological studies, 

324 
symptoms and diagnosis, 327 
treatment, 329 
tendo-vaginitis, 243 
Surface epithelia, 35 
Surgical tuberculosis, 452-480 

clinical forms, 481-504 
Suture of bone, 60 
of muscles, 49 
of nerves, 72-78 
of tendons, 50 
Suturing, 25 

of granulating wounds, 29 
Symmetrical gangrene, 182 
Symptoms of inflammation, 87-104, 127- 

129 
Synovitis, 263, 547 

Swelling a symptom of osteomyelitis, 
262 
in moist gangrene, 185 

Temperature in gangrene, 184 
Tenderness a symptom of osteomyelitis, 
262 

in diagnosis of necrosis, 183 
Tendon -sheaths, tuberculosis of, 565 

pathology, 565 

prognosis, 567 

symptoms and diagnosis, 567 

treatment, 568 
Tendoplasty, 51 
Tenorrhaphy, 50 
Tetanus, 414 

acute, 429 

antitoxin, 433, 434 

bacteriological studies, 414-423 



Tetanus, chronic, 430 

clinical forms, 429 

cultivation, 415 

etiology, 424-427 

hydrophobicus, 430 

infection-atrium, 425 

inoculation experiments, 416 

neonatorum, 430 

pathology and morbid anatomy, 431 

period of incubation, 424 

prognosis, 430 

specific microbic cause, 424 

symptoms and diagnosis, 427 

treatment, 432-435 
Therapeutic inoculation of bacteria, 152 
Third corpuscle, 84 
Thoracoplasty operation, 315 
Thrombosis, 369-373 
Tissue-cells, fixed, 86 
Tissue, condition of, in necrosis, 186 

connective, 41 

granulation, 13 

non-vascular, 30 

vascular, 34 
Tissues, action of bacteria on, 150 

regeneration, 1 
Toxins of bacillus tetani, 421 
Transmission of bacteria, 167 
Transplantation of mucous membrane, 
40 

of skin, 37 
Transudation, inflammatory, 103 
Trauma, 177 

Traumatic erysipelas, 408 
Treatment of acute abscess, 234 

anthrax, 628-631 

brain-abscess, 302 

carbuncle, 248 

chronic abscess, 237 

empyema, 312 

erysipelas, 408 

furuncle, 246 

gangrene, 199 

glanders, 644, 645 

hydrophobia, 446-451 

inflammation, 131-141 

necrosis, 199-203 

paronychia, 244 

phlegmonous inflammation, 238-241 

purulent inflammation, 241-243 

pyaemia, 384-387 



INDEX. 



655 



Treatment of sapraemia, 352-354 
septicaemia, 359, 360 
suppurating wounds, 28 
suppurative arthritis, 290-292 

leptomeningitis, 299 

osteomyelitis, 270-285 ' 

pachymeningitis, 294-296 

peritonitis, 329-331 

tendo-vaginitis, 243 
tetanus, 432-435 
tubercular abscess, 487-493 

tendo-vaginitis, 568-570 
tuberculosis of actinomycosis hom- 
inis, 611 

bladder, 588-590 

bone, 539-544 

epididymis and testicle, 584 

Fallopian tubes, 581 

joints, 554-564 

lymphatic glands, 512-516 

mammary gland, 577 

mouth and tongue, 575 

peritoneum, 521-523 

skin, 502-504 

tendon-sheaths, 568-570 

vulva, vagina, and uterus, 579 
wounds, 23 

skin-grafting in, 39 
Trismus, 430 
Tubercle, fibrous, 477 
hyaline, 478 

nodule, arrangement of cells in, 
474 

growth of, 476 
reticulated, 477 
reticulum, 474 
Tubercular abscess, 484 
ascites, 519 
tendo-vaginitis, 565 

pathology, 565 

prognosis, 567 

symptoms and diagnosis, 567 

treatment, 568-570 
Tuberculosis, surgical, 452 
calcification, 480 
caseation, 478 
description of bacillus, 456 
growth of tubercle-nodules, 476 
hereditary and acquired disposition, 

482 
histogenesis of tubercle, 468 



Tuberculosis, surgical, histological struct- 
ure of tubercle, 470 

histology of tubercle, 466 

history of microbic origin, 452 

inoculation experiments, 459 
tuberculosis in man, 462 

pathological varieties, 477 
Tuberculosis of bladder, 586 

bones, 524-544 

epididymis and testicle, 582 

Fallopian tubes, 579 

fascia, 571 

genito-urinary organs, 578 

glans penis and urethra, 582 

internal ear, 493 

joints, 544-564 

lymphatic glands, 505 

mammary gland, 577 

mouth and tongue, 572 

mucous membrane of intestines, 575 

muscles, 570 

peritoneum, 516 

tendon-sheaths, 565 

the iris, 494 

the skin, 495-504 

vesiculse seminales, 585 

vulva, vagina, and uterus, 578 
treatment, 579 



Ulcer, 250 

diagnosis, 252 

treatment, 253 
Ulcer of foot, 198 

of stomach and duodenum, 197 • 
Ulceration and fistula, 250 
Union of wounds, by primary intention, 
6, 23 

by secondary intention, 27 

immediate or direct, 3 



Vacuolar degeneration, 191 
Varieties of necrosis, 189-203 

of tuberculosis of joints, 547-549 
Vascular tissue, 34 

surface epithelia, 35 
Vascularization of granulation tissue, 16 
Venous circulation, obstructed, 180 
Vesiculce seminales, tuberculosis of, 585 
Vessels, capillary, 80 



656 



INDEX. 



Vulva, vagina, and uterus, tuberculosis 
of, 578 

Wound, cauterization of, 447 
excision of, 446 
healing of, 2 

immediate or direct union, 3 
of blood-vessels, 41 



Wound, skin-grafting in, 39 
suppuration in, 228 
suturing of granulating, 29 
treatment of, 23 

absolute asepsis in, 23, 28 

of suppurating, 28 
union by primary intention, 6, 23 

by secondary intention, 27 




mm 



mmmiiiiiiiiiil^ 

April, 1895. 



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Vienna. Translated and augmented, with the permission of the author, from the 
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FIREBAUGH— The Physician's Wife. 

And the Things that Pertain to Her Life. By Ellen M. Firebatjgh. 
Gracefully written, full of genuine humor, and true to nature, this little volume is a 
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GANT and ALLINGHAM— Diseases of Rectum and Anus. 

By S. G. Gant, M.D., Professor of Rectal and Anal Surgery in the University 
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GOODELL — Lessons in Gynaecology. 

By William Goodelb, A.M., M.D., etc., Professor of Clinical Gynaecology in 
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GRANDIN and JARflAN— Obstetric Surgery. 

By Egbert H. Grandin, M.D., Obstetric Surgeon to the New York Maternity 
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GUERNSEY— Plain Talks on Avoided Subjects. 

By Henry N. Guernsey, M.D., formerly Professor of Materia Medica and 
Institutes in the Hahnemann Medical College of Philadelphia, etc. Contents of the 

Book I. Introductory. II. The Infant. III. Childhood. IV. Adolescence of the 

Male. V. Adolescence of the Female. VI. Marriage: The Husband. VII. The 
Wife. VIII. Husband and Wife. IX. To the Unfortunate. X. Origin of the Sex. 
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HARE — Epilepsy : Its Pathology and Treatment. 

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HARE — Fever: Its Pathology and Treatment. 

Containing Directions and the Latest Information Concerning the Use of the 
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HUIDEKOPER— Age of the Domestic Animals. 

Being a Complete Treatise on the Dentition of the Horse, Ox, Sheep, Hog, and 
Dog, and on the various other means of determining the age of these animals. By 
Rush Shippen Huidekopek, M.D., Veterinarian (Alfort, France) ; Professor of 
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International System of Electrotherapeutics. 

For Students, General Practitioners, and Specialists. Chief Editor, Horatio 
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IVINS — Diseases of the Nose and Throat. 

A Text-Book for Students and Practitioners. By Horace F. Ivins, M.D., 
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* JOAL — On Respiration in Singing. 

For Specialists, Singers, Teachers, Public Speakers, etc. By Dr. Joal (Mont 
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KEATING— Record=Book of Medical Examinations for Life= 
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Designed by John M. Keating, M.D. This record-book is small, but com- 
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KEATING and EDWARDS— Diseases of the Heart and 
Circulation in Infancy and Adolescence. 

With an Appendix entitled " Clinical Studies on the Pulse in Childhood." By 
John M. Keating, M.D., Philadelphia, and William A. Edwards, M.D., Phila- 
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KRAFFT=EBING— A Text=Book on Insanity. 

For the Use of Students and Practitioners. By Dr. R. von Krafft-Ebing. 
Ai.ithorized translation of the Fifth German Edition by Charles Gilbert Chad- 
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LIEBIG and ROHE— Electricity in Medicine and Surgery. 

By G. A. Liebig, Jr., Ph.D., Assistant in Electricity, Johns Hopkins Uni- 
versity, etc. ; and George H. Rohe, M.D., Professor of Obstetrics and Hygiene, 
College of Physicians and Surgeons, Baltimore. Profusely Illustrated by Wood- 
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n ANTON — A Syllabus of Lectures on Human Embryology. 

An Introduction to the Study of Obstetrics and Gynaecology, with a Glossary 
of Embryological Terms. By Walter Porter Manton, M.D., Lecturer on Ob- 
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MASSEY — Electricity in the Diseases of Women. 

With Special Reference to the Application of Strong Currents. By G. Betton 
Massey, M.D., Late Electro-Therapeutist to the Philadelphia Orthopaedic Hospital 
and Infirmary for Nervous Diseases, etc. Second Edition. Revised and Enlarged. 
With New and Original Wood-Engravings. Extra Cloth. 240 pages. 12mo. 

Price, in United States and Canada, SI. 50, net; Great Britain, 8s. 6d. ; 

France, 9 fr. 35. 

riedical Bulletin Visiting List, or Physicians' Call Record. 

Arranged upon an Original and Convenient Monthly and Weekly Plan for the 
Daily Recording of Professional Visits. Handsomely bound in fine strong Leather, 
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fllCHENER— Hand=Book of Eclampsia. 

Or, Notes and Cases of Puerperal Convulsions. By E. Michener, M.D. ; 
J. H. Stubbs, M.D. ; R. B. Ewing, M.D. ; B. Thompson, M.D. ; S. Stebbins, 
M.D. 16mo. Cloth. Price, 60 cts., net. Great Britain, 3s. 6d. 

nONTGOMERY— Practical Gynaecology. 

By E. E. Montgomery, A.M., M.D., Professor of Clinical Gynaecology in the 
Jefferson Medical College, Philadelphia, etc., etc. In one Royal Octavo volume. 
Thoroughly Illustrated. In Preparation. 

*MOORE— fleteorology. 

By J. W. Moore, B.A., M.Ch., University of Dublin ; Fellow and Registrar of 
the Royal College of Physicians of Ireland, etc. Part I. Physical Properties of the 
Atmosphere. Part IE. A Complete History ox the United States Weather Bureau 
from its Beginning to the Present Day, specially contributed by Prof. W. M. 
Harrington, Chief of the "Weather Bureau in Washington, D.C., giving also a full 
list of all the stations under the immediate control of the United States Government. 
Part III. Weather and Climate. Part IV. The Influence of Weather and Season on 
Disease. Profusely Illustrated throughout. One volume. Crown Octavo. Over 400 
pages. Cloth. 

Price, post-paid, in United States and Canada, SS2.00, net ; Great Britain, 
8s. ; France, 9 fr. 50. 

*MYGIND— DeafMMutism. 

By Holgee Mygind, M.D., of Copenhagen. The only authorized English 
Edition. Comprising Introduction, Etiology and Pathogenesis, Morbid Anatomy, 
Symptoms and Sequelae, Diagnosis, Prognosis, and Treatment. Crown Octavo. 
About 300 pages. Cloth. 

Price, post-paid, in United States and Canada, 82.00, net; Great 
Britain, 8s. ; France, 9 fr. 50. 

NISSEN — A Manual of Instruction for Giving Swedish 
Movement and Massage Treatment. 

By Prof. Hartvig Nissen, late Instructor in Physical Culture and Gym- 
nastics at the Johns Hopkins University, Baltimore, Md., etc. With 29 Original 
Wood-Engravings. 12mo. 128 pages. Cloth. 

Price, in United States and Canada, 81.00, net ; Great Britain, 6s. ; 

France, 6 fr. 20. 

Physicians' AllMRequisite Timen and Labor- Saving 
Account-Book. 

Being a Ledger and Account-Book for Physicians' Use, meeting all the Re- 
quirements of the Law and Courts. Designed by William A. Seibert, M.D., of 
Easton, Pa. There is no exaggeration in stating that this Account-Book and Ledger 
reduces the labor of keeping physicians' accounts more than one-half, and at the 
same time secures the greatest degree of accuracy. 

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Physicians' Interpreter. 

In Four Languages, English, French, German, and Italian. Specially arranged 
for diagnosis by M. von V. The plan of the hook is a systematic arrangement of 
questions upon the various branches of Practical Medicine, and each question is so 
worded that the only answer required of the patient is merely Yes or No. Bound in 
full Russia Leather, for carrying in the pocket. Size, 5x2% inches. 206 pages. 
Price, in United States and Canada, $1.00, net ; Great Britain, 6s. ; 

France, 6 fr. 30. 

PURDY— Diabetes. 

Its Cause, Symptoms, and Treatment. By Chas. W. Puedy, M.D., Honorary 
Fellow of the Royal College of Physicians and Surgeons of Kingston ; Author of 
•Bright's Disease and Allied Affections of the Kidneys" ; Member of the Associa- 
tion of American Physicians; Member of the American Medical Association, etc., 
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PURDY — Practical Uranalysis and Urinary Diagnosis. 

A Manual for the Use of Physicians and Students. By Chas. W. Puedy, 
M.D., Author of "Diabetes: its Cause, Symptoms, and Treatment"; Member of the 
Association of American Physicians, etc., etc. With numerous Illustrations, includ- 
ing several Colored Plates. Crown Octavo. About 350 pages. Extra Cloth. 
Price, in United States and Canada, $2.50, net. Great Britain, 14s. ; 

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REriONDINO— History of Circumcision. 

From the Earliest Times to the Present. Moral and Physical Reasons for its 
Performance ; with a History of Eunuchism, Hermaphrodism, etc., and of the 
Different Operations Practiced upon the Prepuce. By P. C. Remondino, M.D., 
Member of the American Medical Association, of the American Public Health 
Association ; Vice-President of California State Medical Society, etc. 12mo. 346 
pages. Extra Cloth. Illustrated with two fine full-page Wood-Engravings, showing 
the two principal modes of Circumcision in ancient times. 

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REflONDINO — The flediterranean Shores of America. 

Southern California : its Climatic, Physical, and Meteorological Conditions. 
By P. C. Remondino, M.D. Royal Octavo. 175 pages. With 45 appropriate Illus- 
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*ROBINSON and CRIBB— The Law and Chemistry Relating 
to Food. 

A Manual for the Use of persons practically interested in the Administration 
of the Law relating to the Adulteration and Unsoundness of Food and Di ugs. By H. 
Mansfield Robinson, LL.D. (London), Solicitor and Clerk to the Shoreditch 

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Sanitary Autnority ; Law Examiner for the British Institute of Public Health, 
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Strand District, etc. Crown Octavo. About 300 pages. 

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ROHE — TextMBook of Hygiene. 

A Comprehensive Treatise on the Principles and Practice of Preventive Medi- 
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Over 450 pages. Extra Cloth. 

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ROHE — A Practical flanual of Diseases of the Skin. 

By George H. Rohe, M.D., assisted by J. Williams Lord, A.B., M.D., Lect- 
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Baltimore, etc. 12mo. Over 300 pages. Extra Cloth. 

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SAJOUS — Hay Fever and its Successful Treatment, 

By Superficial: Organic Alteration of the Nasal Mucous Mem- 
brane. By Charles E. Sajous, M.D., Chief Editor " Annual of the Universal 
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son Medical College, etc. With 13 Engravings on Wood. 12mo. Extra Cloth. 

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*SCHUSTER— When is ilarriage Permissible after Syphilis? 

By Dr. Schuster, of Aix-la-Chapelle. Translated from the German by C. 
Renner, M.D., London. 8vo. 32 pages. Price, 25 cents net, or 1 shilling. 

SENN — Principles of Surgery. 

By N. Senn, M.D., Ph.D., Professor of Principles of Surgery and Surgical 
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SENN — Tuberculosis of the Bones and Joints. 

By N. Senn, M.D., Ph.D., author of a text-book on the "Principles of Sur- 
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of them colored. 

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10 Medical Publications of The F. A. Davis Co., Philadelphia. 



SHOEMAKER— Heredity, Health, and Personal Beauty. 

Including the Selection of the Best Cosmetics for the Skin, Hair, Nails, and 
All Parts Relating to the Body. By John V. Shoemaker, A.M., M.D., Professor 
of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clini- 
cal Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadel- 
phia, etc. Royal Octavo. 425 pages. 

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SHOEMAKER— Ointments and Oleates, 

Especially in Diseases of the Skin. By John V. Shoemaker, A.M., M.D. 
Second Edition, revised and enlarged. 298 pages. 12mo. Extra Cloth. 

Price, in United States and Canada, 881.50, net ; Great Britain, 8s. 6d. ; 

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SHOEMAKER— flateria fledica and Therapeutics. 

With Especial Reference to the Clinical Application of Drugs. By John V. 
Shoemaker, A.M., M.D., Professor of Materia Medica, Pharmacology and Thera- 
peutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the 
Medico-Chirurgical College of Philadelphia, etc. Second Edition, Thoroughly 
Revised. In Two Volumes. Royal Octavo. Nearly 1100 pages. The volumes may 
be purchased separately. 

Volume I (354 pages) is devoted to Pharmacy, general Pharmacology and 
Therapeutics, and remedial agents not properly classed with drugs. 

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Volume II (700 pages) is wholly taken up with the consideration of drugs, 
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Therapy. 

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Each volume is thoroughly and carefully indexed with clinical and general 
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doses extending over several double-column octavo pages. 

SniTH — Physiology of the Domestic Animals. 

A Text-Book for Veterinary and Medical Students and Practitioners. By 
Robert Meade Smith, A.M., M.D., formerly Professor of Comparative Physi- 
ology in University of Pennsylvania, etc. Royal Octavo. Over 950 pages. Profusely 
illustrated with more than 400 fine Wood-Engravings, some of them Colored. 
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SOZINSKEY— riedical Symbolism. 

Historical Studies in the Arts of Healing and Hygiene. By Thomas S. Sozins- 
key, M.D., Ph.D., Author of "The Culture of Beauty," "The Care and Culture of 



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Children," etc. 12mo. Nearly 200 pages. Extra Cloth. Appropriately illustrated 
with thirty (30) new Wood-Engravings. 

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STEWART— Obstetric Synopsis. 

A Complete Compend. By John 8. Stewart, M.D., late Demonstrator of 
Obstetrics in the Medico-Chirurgical College of Philadelphia; with an introductory 
note by William S. Stewart, A.M., M.D., Emeritus Professor of Obstetrics and 
Gynaecology in the Medico-Chirurgical College of Philadelphia. 42 Illustrations. 
202 pages. 12mo. Extra Blue Cloth. 

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STRAUB — Symptom Register and Case Record. 

Designed by D. W. Steaub, M.D. Giving in plain view, on one side of the 
sheet 7% x 10% inches, the Clinical Record of the sick, including Date, Name, Resi- 
dence, Occupation, Symptoms, Inspection (Auscultation and Percussion), History, 
Respiration, Pulse, Temperature, Diagnosis, Prognosis, Treatment (special and 
general), and Remarks, all conveniently arranged, and with ample room for record- 
ing, at each call, for four different calls, each item named above, the whole forming 
a clinical history of individual cases of great value to every Practitioner. 

Published in stiff Board Tablets, of 50 sheets each, at 50 cents, net, per 
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*THRESH— Water Supplies. 

By J. C. Thresh, D.Sc.Lond., M.B., F.I.C., F.C.S., Lecturer in Sanitary 
Science, King's College, London, etc. City Authorities, Town Councils, Levy 
Courts, County Councils, Farmers, Owners of Villas or Private Residences in the 
Country, Settlers in newly-opened Districts, Colonists, etc., will find this little book 
of extreme value, as it contains practical hints with excellent illustrations by the 
score. Illustrated. One Volume. Crown Octavo. About 300 pages. Cloth. 

Price, in the United States and Canada, S3. OO, net ; Great Britain, 8s. ; 

France, 9 fr. 50. 

^Transactions of the fleetings of the British Laryngological 
Association. 

Volume I, 1891. Royal 8vo. 108 pages. Cloth. Price, 2s. 6d. (75 cents, net). 
Volume II, 1892. Royal 8vo. 100 pages. Cloth. Price, 2s. 6d. (75 cents, net). 
Volume III, 1893. Royal 8vo. 106 pages. Price, 2s. 6d. (75 cents, net). 
The three volumes together, 6s. (882.00, net). 

ULTZnANN— The Neuroses of the Genito=Urinary System 
in the flale. 

With Sterility and Impotence. By Dr. Ultzmann, Professor of Genito- 
urinary Diseases in the University of Vienna. Translated, with the author's per- 
mission, by Gardner W. Allen, M.D., Surgeon in the Genito- Urinary Depart- 
ment, Boston Dispensary. Illustrated. 12mo. Extra Cloth. 

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12 Medical Publications of the F. A. Davis Co., Philadelphia. 



VOUGHT — Chapter on Cholera for Lay Readers. 

History, Symptoms, Prevention, and Treatment of the Disease. By Walter 
Votjght, Ph.B., M.D., late Medical Director and Physician-in-Charge of the Fire 
Island Quarantine Station, Port of New York ; Fellow of the New York Academy of 
Medicine, etc. Illustrated. 12ino. 106 pages. Flexible Cloth. 

Price, in United States and Canada, 75 cents, net ; Great Britain, 4s. ; 

France, 5 fr. 

WITHERSTINE— International Pocket Medical Formulary. 

Arranged Therapeutically. By C. Sumner Witherstine, A.M., M.D., Vis- 
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YOUNG — Synopsis of Human Anatomy. 

Being a Complete Compend of Anatomy, including the Anatomy of the Viscera, 
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Annual of the Universal Medical Sciences. 

A Yearly Report of the Progress of the General Sanitary Sciences Throughout 
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History of Universal Medicine. 

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Medical Publications of The F. A. Davis Co., Philadelphia. 13 



ADAMS— History of the Life of D. Hayes Agnew, n.D., LL.D. 

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KRAFFT=EBING— Psychopathia Sexualis. 

With Especial Reference to Contrary Sexual Instinct : A Medico-Legal Study 
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RANNEY — Lectures on Nervous Diseases. 

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SAJOUS — Lectures on the Diseases of the Nose and Throat. 

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SCHRENCK=NOTZING— Suggestive Therapeutics in Psy- 
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11 Medical Publications of The F. A. Davis Co., Philadelphia. 

STANTON — The Encyclopedia Ofl l : ace and Form Reading. 

< » r Personal Traits, i">th Physical and Mental, Revealed by Outward v 
igb Practical and Scientific Physiognomy • Being a . Manual <>t Instruction in 
tin- Knot I lbs Human Physiognomy and Organism, Bj MaJtl Ouffl 

tlcal and Boientiflc Treatise on Physiognomy" ; "A 
Chart foi iii. [ental and Pbyslological Characteristics," eta With 

an outline ol itu< in 1 .ia»^ifir.i -u^ci^ti\«' niu'stion^ and elaborate aids 

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^Journal of Laryngology! Rhlnology, and Otology. 

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The rtedical Bulletin. 

t. Monthly Journal ol Medich • i ditedbyJoHv V.Shoi 

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ii profession throngboul tin- world. Bnbscrlbe now. 

us, »i.oo in Qnited B I ids, and M< 

■ Shillings 8 Iran. - ; I ; . I ] SU ; 

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The Universal "ledical Journal. 

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•■ Annual "t the Universal Medical Sci< 

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IN PREPARATION FOR EARLY PUBLICATION. 
Pregnancy, Labor, and the Puerperal State. 

By Egbert H. Grani.in. M.D., and Geoegb W. Jarman, MJ). Profusely 
illustrated with handsome full-page photographic plates and numerous wood-outs. 
Royal octavo. A companion volume to " Obstetric Surgery," by the same authors. 
(See page 4.) The two volumes form a complete modern treatise on the Science 
and Art of Obstetrics. 



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